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Paasch C, Kobelt E, Lünse S, Heisler S, Lorenz R, Hunger R, Mantke R. How often is prophylactic parastomal mesh placement performed after rectal resection without sphincter preservation? An analysis of German nationwide hospital discharge data among 41,697 patients. Hernia 2024; 28:9-15. [PMID: 37843603 PMCID: PMC10891180 DOI: 10.1007/s10029-023-02887-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE The European Hernia Society guidelines of parastomal hernias, published in 2017, strongly recommend prophylactic synthetic non-absorbable mesh upon the construction of a permanent end colostomy to reduce the incidence of parastomal hernias. This study aims to evaluate the implementation of the guidelines in Germany. METHODS This is a retrospective multicentric analysis conducted in December 2022 at the University Hospital Brandenburg an der Havel. Anonymous data on rectal resection without sphincter preservation in the period 2010-2020 were extracted from the German nationwide hospital discharge data set. Individuals with a hernia and < 18 years old were excluded. Another exclusion criterion was a performed colectomy or proctocolectomy with an ileoanal pouch and placement of an absorbable mesh. The primary endpoint was the annual rate of prophylactic parastomal mesh placement following rectal resection without sphincter preservation in Germany. Cases reporting both non-absorbable mesh placement and rectal resection without sphincter preservation were considered prophylactic mesh insertions. RESULTS A total of 41,697 patients received a rectal resection without sphincter preservation and without non-absorbable mesh placement. Among these individuals, 27,089 were male and 14,608 were female. The rate of reoperations (3.1%) and the length of hospital stay (25.3 days ± 19.32) remained almost constant during these 10 years. The rate of prophylactic mesh placement was increasing from 0.2% (n = 8) in 2010 to 6.4% (n = 198) in 2020. CONCLUSIONS Currently, only the minority of patients who have undergone rectal resection without sphincter preservation receive prophylactic mesh insertion.
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Affiliation(s)
- C Paasch
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany.
- Clinic for General and Visceral Surgery, University Hospital Brandenburg an der Havel, Brandenburg Medical University, Hochstraße 29, 14770, Brandenburg an der Havel, Germany.
| | - E Kobelt
- Faculty of Health Science Brandenburg, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
| | - S Lünse
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
| | - S Heisler
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
| | - R Lorenz
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
- Hernia Center 3+CHIRURGEN, Berlin, Germany
| | - R Hunger
- Faculty of Health Science Brandenburg, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
| | - R Mantke
- Department of Surgery, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
- Faculty of Health Science Brandenburg, Brandenburg Medical School, University Hospital Brandenburg/Havel, 14770, Brandenburg, Germany
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Verdaguer-Tremolosa M, Garcia-Alamino JM, Rodrigues-Gonçalves V, Martínez-López MP, López-Cano M. Prophylactic mesh does not prevent parastomal hernia in long-term: Meta-analysis and trial sequential analysis. Surgery 2024; 175:441-450. [PMID: 37949696 DOI: 10.1016/j.surg.2023.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Previous randomized clinical trials, systematic reviews, and meta-analyses evaluating parastomal hernia prevention with mesh placement during end colostomy formation have reported contradictory results. This review aimed to assess the efficacy of this strategy in long-term follow-up according to the latest available data. METHODS Medline, EMBASE, Cochrane Library, Web of Science, and Google Scholar were searched. Randomized clinical trials were included if they compared mesh with no mesh during initial end colostomy creation in adult patients to prevent parastomal hernia with a follow-up longer than 2 years. A meta-analysis was performed to evaluate parastomal hernia incidence (primary outcome), parastomal hernia repair rate, and mortality. Subgroup analysis included surgical approach and mesh position, and trial sequential analysis was performed. RESULTS Eight randomized clinical trials involving 537 patients met the inclusion criteria. Based on long-term follow-up, the incidence of parastomal hernia was not reduced when a prophylactic mesh was placed (relative risk = 0.68 [95% confidence interval:0.46-1.02]; I2 = 81%, P =.06). The parastomal hernia repair rate was low; however, no difference was found between the groups (relative risk = 0.90 [95% confidence interval:0.51-1.56]; I2 = 0%; P = .70), and no difference was detected between the groups when mortality was assessed (relative risk = 1.03 [95% confidence interval: 0.77-1.39]; I2 = 21%; P = .83). Subgroup analyses did not show differences according to the surgical approach or mesh position used. Regarding trial sequential analysis, an optimal information size was not achieved. CONCLUSION Prophylactic mesh placement during end colostomy formation does not prevent parastomal hernia in the long term. The parastomal hernia repair rate and mortality rate did not vary between the included groups. Heterogeneity among the included randomized clinical trials might restrict the reliability of the results.
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Affiliation(s)
- Mireia Verdaguer-Tremolosa
- Abdominal Wall Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Josep Maria Garcia-Alamino
- Department of Health Sciences, Universitat Blanquerna-Ramon Llull, Barcelona, Spain. http://www.twitter.com/JosepMGarcia75
| | - Victor Rodrigues-Gonçalves
- Abdominal Wall Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. http://www.twitter.com/VictRodriguesG
| | - Maria Pilar Martínez-López
- Abdominal Wall Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. http://www.twitter.com/Piilaarr
| | - Manuel López-Cano
- Abdominal Wall Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. http://www.twitter.com/ManuelLpezCano1
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Krogsgaard M, Dreyer P, Thomsen T. Understanding patients' perspectives when unprepared for the emergence of a parastomal bulge-a qualitative study. Colorectal Dis 2023; 25:2198-2205. [PMID: 37814485 DOI: 10.1111/codi.16750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/14/2023] [Accepted: 08/03/2023] [Indexed: 10/11/2023]
Abstract
AIM The aim was to investigate patients' experiences of being prepared for the development of a parastomal bulge in relation to a stoma. METHODS The paper draws on a qualitative interview study conducted with 20 Danish patients participating in five focus groups. Analysis was performed using a phenomenological-hermeneutic approach. RESULTS We identified three themes. The first theme is 'The unforeseen bulge gives rise to increasing concern and a search for an explanation'. Patients searched for explanations in their own life and suspected that their behaviour or previous illness induced the bulge. The second theme is 'Missing or confusing information leads to counterproductive behaviour'. Patients lacked information on the prevention and treatment of parastomal bulging which led to disappointment with healthcare professionals. The third theme is 'Weighing the pros and cons of life with the bulge against the gamble of surgical repair'. Some patients came to terms with their situation, but for others a deadlocked situation arose when surgical repair was not an option. CONCLUSION Healthcare communication directly impacts on patients' experiences and outcomes. When unprepared for the emergence of a parastomal bulge, patients' emotional and psychological well-being are affected and likewise patients' possibility of using their own health beliefs as a preventive strategy. To preserve patient autonomy, satisfaction and well-being, surgeons and stoma nurses should provide patients with tailored information bearing in mind the current lack of clear evidence on the prevention and treatment of parastomal bulging.
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Affiliation(s)
- Marianne Krogsgaard
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege, Denmark
| | - Pia Dreyer
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health, Section of Nursing Science, Aarhus University, Aarhus, Denmark
| | - Thordis Thomsen
- Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Stabilini C, Muysoms FE, Tzanis AA, Rossi L, Koutsiouroumpa O, Mavridis D, Adamina M, Bracale U, Brandsma HT, Breukink SO, López Cano M, Cole S, Doré S, Jensen KK, Krogsgaard M, Smart NJ, Odensten C, Tielemans C, Antoniou SA. EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:11549. [PMID: 38312414 PMCID: PMC10831651 DOI: 10.3389/jaws.2023.11549] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/11/2023] [Indexed: 02/06/2024]
Abstract
Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.
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Affiliation(s)
| | - Filip E. Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | | | - Lisa Rossi
- Department of Surgery, IRCCS Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ourania Koutsiouroumpa
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
| | - Umberto Bracale
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | | | - Manuel López Cano
- Abdominal Wall Surgery Unit, Val d’ Hebrón University Hospital, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Neil J. Smart
- Department of General Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Christoffer Odensten
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University Educational Unit at Sunderby Hospital, Sunderby, Sweden
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Tzanis AA, Stabilini C, Muysoms FE, Rossi L, Koutsiouroumpa O, Mavridis D, Adamina M, Bracale U, Brandsma HT, Breukink SO, López Cano M, Cole S, Doré S, Jensen KK, Krogsgaard M, Smart NJ, Odensten C, Tielemans C, Antoniou SA. Update Systematic Review, Meta-Analysis and GRADE Assessment of the Evidence on Parastomal Hernia Prevention-A EHS, ESCP and EAES Collaborative Project. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:11550. [PMID: 38312423 PMCID: PMC10831653 DOI: 10.3389/jaws.2023.11550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/11/2023] [Indexed: 02/06/2024]
Abstract
Objective: To perform a systematic review and meta-analysis on the effectiveness of prophylactic mesh for the prevention of parastomal hernia in end colostomy, with the ultimate objective to summarize the evidence for an interdisciplinary, European rapid guideline. Methods: We updated a previous systematic review with de novo evidence search of PubMed from inception up to June 2022. Primary outcome was quality of life (QoL). Secondary outcomes were clinical diagnosis of parastomal hernia, surgery for parastomal hernia, and 30 day or in-hospital complications Clavien-Dindo ≥3. We utilised the revised Cochrane Tool for randomised trials (RoB 2 tool) for risk of bias assessment in the included studies. Minimally important differences were set a priori through voting of the panel members. We appraised the evidence using GRADE and we developed GRADE evidence tables. Results: We included 12 randomized trials. Meta-analysis suggested no difference in QoL between prophylactic mesh and no mesh for primary stoma construction (SMD = 0.03, 95% CI [-0.14 to 0.2], I2 = 0%, low certainty of evidence). With regard to parastomal hernia, the use of prophylactic synthetic mesh resulted in a significant risk reduction of the incidence of the event, according to data from all available randomized trials, irrespective of the follow-up period (OR = 0.33, 95% CI [0.18-0.62], I2 = 74%, moderate certainty of evidence). Sensitivity analyses according to follow-up period were in line with the primary analysis. Little to no difference in surgery for parastomal hernia was encountered after pooled analysis of 10 randomised trials (OR = 0.52, 95% CI [0.25-1.09], I2 = 14%). Finally, no significant difference was found in Clavien-Dindo grade 3 and 4 adverse events after surgery with or without the use of a prophylactic mesh (OR = 0.77, 95% CI [0.45-1.30], I2 = 0%, low certainty of evidence). Conclusion: Prophylactic synthetic mesh placement at the time of permanent end colostomy construction is likely associated with a reduced risk for parastomal hernia and may confer similar risk of peri-operative major morbidity compared to no mesh placement. There may be no difference in quality of life and surgical repair of parastomal hernia with the use of either approach.
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Affiliation(s)
| | | | - Filip E. Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | - Lisa Rossi
- Department of Surgery, IRCCS Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ourania Koutsiouroumpa
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
| | - Umberto Bracale
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | | | - Manuel López Cano
- Abdominal Wall Surgery Unit, Val d’ Hebrón University Hospital, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Neil J. Smart
- Department of General Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Christoffer Odensten
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University Educational Unit at Sunderby Hospital, Sunderby, Sweden
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