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Marcolin P, Mazzola Poli de Figueiredo S, Oliveira Trindade B, Bueno Motter S, Brandão GR, Mao RMD, Moffett JM. Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis. Hernia 2024:10.1007/s10029-023-02943-4. [PMID: 38252397 DOI: 10.1007/s10029-023-02943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/08/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy. METHODS We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934). RESULTS We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation. CONCLUSIONS Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.
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Affiliation(s)
- P Marcolin
- School of Medicine, Universidade Federal da Fronteira Sul, Passo Fundo, RS, Brazil.
| | | | - B Oliveira Trindade
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - S Bueno Motter
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - G R Brandão
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - R-M D Mao
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - J M Moffett
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
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2
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DeAngelo N, Perez AJ. Hernia Prevention: The Role of Technique and Prophylactic Mesh to Prevent Incisional Hernias. Surg Clin North Am 2023; 103:847-857. [PMID: 37709391 DOI: 10.1016/j.suc.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Millions of laparotomies are performed annually, carrying up to a 41% risk of developing into a hernia. Incisional hernias are associated with morbidity, mortality, and costs; an estimated $9.6 billion is spent annually on repair of ventral hernias. Although repair is possible, surgeons must prevent incisional hernias from occurring. There is substantial evidence on surgical technique to reduce the risk of incisional hernia formation. This article aims to critically summarize the use of surgical technique and prophylactic mesh augmentation during fascial closure to inform decision-making and reduce incisional hernia formation.
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Affiliation(s)
- Noah DeAngelo
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Arielle J Perez
- The University of North Carolina at Chapel Hill, Department of Surgery, 160 Dental Circle, Burnett-Womack, CB #7228, Chapel Hill, NC 27599-7228, USA.
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3
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Jakob MO, Brüggemann A, Moser N, Candinas D, Beldi G, Haltmeier T. Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields. Surg Endosc 2023; 37:6885-6894. [PMID: 37311892 PMCID: PMC10462502 DOI: 10.1007/s00464-023-10144-4] [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: 03/07/2023] [Accepted: 05/16/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields. METHODS Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors. RESULTS A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001). CONCLUSION This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.
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Affiliation(s)
- Manuel O Jakob
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adriana Brüggemann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Moser
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Coelho R, Dhanani NH, Lyons NB, Bernardi K, Askenasy EP, Millas S, Holihan JL, Ali Z, Liang MK. Hernia Prevention Using Biologic Mesh and/or Small Bites: A Multispecialty 2 × 2 Factorial Randomized Controlled Trial. J Am Coll Surg 2023; 237:309-317. [PMID: 37458369 PMCID: PMC10574223 DOI: 10.1097/xcs.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Ventral incisional hernias are the most common complication after abdominal operation. Randomized trials have shown efficacy of prophylactic synthetic mesh and small bites. Adoption of these practices has been limited due to concerns with placement of synthetic mesh in contaminated cases and small bites in an overweight population. We sought to assess the efficacy of prophylactic biologic mesh and small bites to prevent postoperative major complications: ventral incisional hernias, surgical site infection, reoperation, and death. STUDY DESIGN High-risk patients (overweight/obese, current smoker) undergoing abdominal operation with a midline incision (5 cm or greater) were randomized (2 × 2 factorial trial) to receive either sublay biologic mesh or no mesh and either small bites (0.5 × 0. 5cm) or large bites (1 × 1 cm) fascial closure. The primary outcome measure was major complications at 1 year postoperative. CONSORT guidelines were followed, and this study was registered on clinicaltrials.gov (NCT03148496). Assuming α = 0.05, β = 0.20, and Δ = 20%, it was estimated that 105 patients were needed. Primary outcome was assessed using Fisher's exact test. RESULTS A total of 107 patients were randomized: 52 (49%) to mesh, 55 (51%) to no mesh, 55 (51%) to small bites, and 52 (49%) to large bites. Of the patients, 16% were smokers, 31% were overweight, and 55% were obese. At 1 year postoperative, there were no differences in major complications between groups (mesh vs no mesh 21% vs 16%, p = 0.62; small vs large bites 18% vs 19%, p = 1.00). CONCLUSIONS In this trial, biologic mesh and small bites appear to have no benefit. Further randomized trials are needed among high-risk patients before widespread adoption of prophylactic biologic mesh or small bites.
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Affiliation(s)
- Rainna Coelho
- From the Department of Surgery, University of Houston, Hospital Corporation of America Kingwood, Kingwood, TX (Coelho, Ali, Liang)
| | - Naila H Dhanani
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL (Lyons)
| | - Karla Bernardi
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Erik P Askenasy
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Stefanos Millas
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Dhanani, Bernardi, Askenasy, Millas, Holihan)
| | - Zuhair Ali
- From the Department of Surgery, University of Houston, Hospital Corporation of America Kingwood, Kingwood, TX (Coelho, Ali, Liang)
| | - Mike K Liang
- From the Department of Surgery, University of Houston, Hospital Corporation of America Kingwood, Kingwood, TX (Coelho, Ali, Liang)
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Deerenberg EB, Henriksen NA, Antoniou GA, Antoniou SA, Bramer WM, Fischer JP, Fortelny RH, Gök H, Harris HW, Hope W, Horne CM, Jensen TK, Köckerling F, Kretschmer A, López-Cano M, Malcher F, Shao JM, Slieker JC, de Smet GHJ, Stabilini C, Torkington J, Muysoms FE. Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies. Br J Surg 2022; 109:1239-1250. [PMID: 36026550 PMCID: PMC10364727 DOI: 10.1093/bjs/znac302] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/28/2022] [Accepted: 08/05/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. METHODS A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. RESULTS Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. CONCLUSION These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions.
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Affiliation(s)
- Eva B Deerenberg
- Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | - Nadia A Henriksen
- Department of Hepatic and Digestive diseases, Herlev University Hospital, Copenhagen, Denmark
| | - George A Antoniou
- Department of Vascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stavros A Antoniou
- Mediterranean Hospital of Cyprus, Limassol, Cyprus.,Medical School, European University Cyprus, Nicosia, Cyprus
| | - Wichor M Bramer
- Medical Library, Erasmus MC, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - John P Fischer
- Department of Plastic Surgery, University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Rene H Fortelny
- Certified Hernia Center, Wilhelminenspital, Veinna, Austria.,Paracelsus Medical, University Salzburg, Salzburg, Austria
| | - Hakan Gök
- Hernia Istanbul®, Hernia Surgery Centre, Istanbul, Turkey
| | - Hobart W Harris
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - William Hope
- Department of Surgery, Novant/New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - Charlotte M Horne
- Department of Surgery, Penn State Health Department, Hershey, Pennsylvania, USA
| | - Thomas K Jensen
- Department of Hepatic and Digestive diseases, Herlev University Hospital, Copenhagen, Denmark
| | - Ferdinand Köckerling
- Hernia Center, Vivantes Humboldt-Hospital, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany
| | - Alexander Kretschmer
- Klinikum der Ludwig-Maximillians-Universität München, Munchen, Germany.,Janssen Oncology, Los Angeles, CA, USA
| | - Manuel López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Unviversitat Autònoma de Barcelona, Barcelona, Spain
| | - Flavio Malcher
- Department of Surgery, NYU Langone Health/NYU Grossman School of Medicine, New York, New York, USA
| | - Jenny M Shao
- Division of Gastrointestinal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Gijs H J de Smet
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Cesare Stabilini
- Department of Surgery, Policlinico San Martino IRCCS and Department of Surgical Sciences, University of Genoa, Genoa, Italy
| | - Jared Torkington
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - Filip E Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
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6
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Albendary M, Mohamedahmed AYY, Alamin A, Rout S, George A, Zaman S. Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:1333-1344. [PMID: 35020082 DOI: 10.1007/s00423-021-02421-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh. METHODS A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS). RESULTS Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84). CONCLUSION The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.
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Affiliation(s)
- Mohamed Albendary
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK.
| | | | - Shantanu Rout
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Anil George
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
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7
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OUP accepted manuscript. Br J Surg 2022; 109:754-762. [DOI: 10.1093/bjs/znac107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/13/2022]
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8
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Peltrini R, Imperatore N, Altieri G, Castiglioni S, Di Nuzzo MM, Grimaldi L, D'Ambra M, Lionetti R, Bracale U, Corcione F. Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis. Hernia 2021; 25:639-648. [PMID: 33713204 PMCID: PMC8197707 DOI: 10.1007/s10029-021-02393-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
Purpose To evaluate safety and efficacy of a mesh reinforcement following stoma reversal to prevent stoma site incisional hernia (SSIH) and differences across the prostheses used. Methods A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases was conducted to identify comparative studies until September 2020. A meta-analysis of postoperative outcomes and a network meta-analysis for a multiple comparison of the prostheses with each other were performed. Results Seven studies were included in the analysis (78.4% ileostomy and 21.6% colostomy) with a total of 1716 patients with (n = 684) or without (n = 1032) mesh. Mesh placement was associated with lower risk of SSIH (7.8%vs18.1%, OR0.266,95% CI 0.123–0.577, p < 0.001) than no mesh procedures but also with a longer operative time (SMD 0.941, 95% CI 0.462–1.421, p < 0.001). There was no statistically significant difference in terms of Surgical Site infection (11.5% vs 11.1%, OR 1.074, 95% CI 0.78–1.48, p = 0.66), seroma formation (4.4% vs 7.1%, OR 1.052, 95% CI 0.64–1.73, p = 0.84), anastomotic leakage (3.7% vs 2.7%, OR 1.598, 95% CI 0.846–3.019, p = 0.149) and length of stay (SMD − 0.579,95% CI − 1.261 to 0.102, p = 0.096) between mesh and no mesh groups. Use of prosthesis was associated with a significant lower need for a reoperation than no mesh group (8.1% vs 12.1%, OR 0.332, 95% CI 0.119–0.930, p = 0.036). Incidence of seroma is lower with biologic than polypropylene meshes but they showed a trend towards poor results compared with polypropylene or biosynthetic meshes. Conclusion Despite longer operative time, mesh prophylactic reinforcement at the site of stoma seems a safe and effective procedure with lower incidence of SSIH, need for reoperation and comparable short-term outcomes than standard closure technique. A significant superiority of a specific mesh type was not identified. Supplementary Information The online version contains supplementary material available at 10.1007/s10029-021-02393-w.
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Affiliation(s)
- Roberto Peltrini
- Department of Public Health, University of Naples Federico II, Naples, Italy.
| | - Nicola Imperatore
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.,Gastroenterology and Endoscopy Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Gaia Altieri
- Departement of Gastroenterological, Endocrine-Metabolic and Nephrourological Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Castiglioni
- Department of Medical, Oral and Biotechnological Sciences, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
| | | | - Luciano Grimaldi
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Michele D'Ambra
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Umberto Bracale
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, Naples, Italy
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