Obesity is a significant risk factor for ileostomy site incisional hernia following reversal

Risk factors associated to incisional hernia in stoma site after stoma closure: A systematic review and meta-analysis

BACKGROUND

This study aims to identify which risk factors are associated with the appearance of an incisional hernia in a stoma site after its closure. This in the sake of identifying which patients would benefit from a preventative intervention and thus start implementing a cost-effective protocol for prophylactic mesh placement in high-risk patients.

METHODS

A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. Studies reporting incidence, risk factors, and follow-up time for appearance of incisional hernia after stoma site closure were included. A fixed-effects and random effects models were used to calculate odds ratios' estimates and standardized mean values with their respective grouped 95% confidence interval. This to evaluate the association between possible risk factors and the appearance of incisional hernia after stoma site closure.

RESULTS

Seventeen studies totaling 2899 patients were included. Incidence proportion between included studies was of 16.76% (CI95% 12.82; 21.62). Out of the evaluated factors higher BMI (p = 0.0001), presence of parastomal hernia (p = 0.0023), colostomy (p = 0,001), and end stoma (p = 0.0405) were associated with the appearance of incisional hernia in stoma site after stoma closure, while malignant disease (p = 0.0084) and rectum anterior resection (p = 0.0011) were found to be protective factors.

CONCLUSIONS

Prophylactic mesh placement should be considered as an effective preventative intervention in high-risk patients (obese patients, patients with parastomal hernia, colostomy, and end stoma patients) with the goal of reducing incisional hernia rates in stoma site after closure while remaining cost-effective.

Incidence, risk factors, and predictive modeling of stoma site incisional hernia after enterostomy closure: a multicenter retrospective cohort study

PURPOSE

Stoma site incisional hernia (SSIH) is a common complication, but its incidence and risk factors are not well known. The objective of this study is to explore the incidence and risk factors of SSIH and build a predictive model.

METHODS

We performed a multicenter retrospective analysis on the patients who underwent enterostomy closure from January 2018 to August 2020. Patient's general condition, perioperative, intraoperative, and follow-up information was collected. The patients were divided into control group (no occurrence) and observation group (occurrence) according to whether SSIH occurred. Univariate and multivariate analysis were used to evaluate the risk factors of SSIH, following which we constructed a nomogram for SSIH prediction.

RESULTS

One hundred fifty-six patients were enrolled in the study. The incidence of SSIH was 24.4% (38 cases), of which 14 were treated with hernia mesh repair, and the others were treated with conservative treatment. Univariate and multivariate analysis showed that age ≥ 68 years (OR 1.045, 95% CI 1.002 ~ 1.089, P = 0.038), colostomy (OR 2.913, 95% CI 1.035 ~ 8.202, P = 0.043), BMI ≥ 25 kg/m2 (OR 1.181, 95% CI 1.010 ~ 1.382, P = 0.037), malignant tumor (OR 4.838, 95% CI 1.508 ~ 15.517, P = 0.008) and emergency surgery (OR 5.327, 95% CI 1.996 ~ 14.434, P = 0.001) are the independent risk factors for SSIH.

CONCLUSIONS

Based on the results, a predictive model for the occurrence of SSIH was constructed to screen high-risk groups of SSIH. For patients at high risk for SSIH, how to deal with the follow-up and prevent the occurrence of SSIH is worth further exploration.

Satisfactory short-term outcomes of totally laparoscopic ileostomy reversal compared to open surgery in colorectal cancer patients

Background

Recently, totally laparoscopic (TLAP) surgery has suggested its potential on ileostomy reversal. This study aimed to compare the short-term outcomes between TLAP and traditional open ileostomy reversal.

Patients and methods

From September 2016 to September 2021, 107 eligible patients underwent TLAP (n = 48) or open (n = 59) loop ileostomy reversal were retrospectively enrolled. Surgical parameters, postoperative recovery and complications were identified and compared between TLAP technique vs. open surgery.

Results

The operation time and estimated blood loss showed no obvious difference between TLAP and open group. However, TLAP reversal significantly decreased the incision length (4.5cm vs. 6cm, P < 0.001). Furthermore, patients underwent TLAP surgery showed quicker first ground activities (1 day vs. 2 days, P < 0.001), faster first flatus passage (2 days vs. 3 days, P = 0.004) and shorter postoperative stay (5 days vs. 7 days, P = 0.007). More importantly, postoperative complications were significantly reduced after TLAP reversal (3 cases vs. 10 cases, P = 0.026). Further logistic regression analyses also indicated the TLAP technique was associated with lower incidence of complications (OR=3.316, CI, 1.118-9.835; P = 0.031).

Conclusions

TLAP surgery is competitive in promoting postoperative recovery as well as reducing complications compared to the traditional open ileostomy reversal.

Incisional Hernia Development after Live Donor Nephrectomy: Impact of Surgical Technique

BACKGROUND

Characteristics of incisional hernia (IH) formation after live donor nephrectomy (LDN) are not well-defined. The goal of this study was to describe the incidence of IH within 3 years after LDN and identify risk factors contributing to their formation.

METHODS

We performed a single-center, retrospective review of all LDN between February 2013 and October 2018. Patients with and without IH were compared based on donor and operative variables. Data were analyzed using chi-square tests with column proportions. Multivariable logistic regression with backward elimination was used to evaluate the likelihood of IH on the basis of potential risk factors.

RESULTS

Three hundred one individuals underwent live donor nephrectomy. Twenty-eight patients (9.3%) developed an IH, with a median time to development of 7 months (range: 2-24 months). Obesity (body mass index ≥30), periumbilical hand port, and vertical infraumbilical hand port were associated with increased risk of IH development on univariate analysis. On multivariate analysis, obesity and periumbilical hand port location were persistent risk factors for IH.

CONCLUSIONS

The incidence of IH after LDN is prevalent and associated with obesity and operative technique. Placing the hand port infraumbilical with a transverse fascial incision may reduce the risk of IH after LDN.

Incidence and risk factors of delayed development for stoma site incisional hernia after ileostomy closure in patients undergoing colorectal surgery with temporary ileostomy

BACKGROUND

Stoma site incisional hernias after ileostomy closure are complex hernias that can be associated with abdominal pain, discomfort, and a diminished quality of life. The aim of this study was to determine the incidence of incisional hernia (IH) following temporary ileostomy reversal in patients undergoing colorectal surgery, and the risk factors associated with its development.

METHODS

This was a prospective, single-centre, cohort study of patients undergoing ileostomy reversal between January 2010 and December 2016. Comorbidities, operative characteristics, comparison between early and late ileostomy closure and postoperative complications were analysed.

RESULTS

A total of 202 consecutive patients were prospectively evaluated (median follow-up 46 months; range: 12-109). Stoma site incisional hernia occurred in 23% of patients (n = 47), diagnosed by physical examination or imaging tests. The reasons for the primary surgery were colorectal cancer (n = 141, 69.8%), inflammatory bowel disease (n = 14, 6.9%), emergency surgery (n = 35, 17.3%), and other conditions (n = 12, 5.9%). Secondary outcomes: a statistically significant risk factors for developing an IH was obesity (higher BMI) (OR 1.15, 95% CI: 1.05-1.26) p = .003).

CONCLUSIONS

23% of patients developed surgical site IH, a higher BMI being the only risk factor found to be statistically significant in the development of an incisional hernia.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience

BACKGROUND

Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site.

METHOD

A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure.

RESULTS

A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group.

DISCUSSION

The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.

When to use a prophylactic mesh after stoma closure: a case-control study

Purpose

The closure of a stoma is frequently associated with an acceptable morbidity and mortality. One of the most frequent complications is incisional hernia at the stoma site, which occurs in 20%–40% of cases, higher than incisions in other parts of the abdomen. The objective of this study was to identify the risk factors associated with the presentation of incisional hernia after stoma closure, this in order to select patients who are candidates for prophylactic mesh placement during closure.

Methods

An unpaired case–control study was conducted. This study involved 164 patients who underwent a stoma closure between January 2014 and December 2019. Associated factors for the development of incisional hernia at the site of the stoma after closure were identified, for which it was performed a logistic regression analysis.

Results

41 cases and 123 controls were analyzed, with a mean follow-up of 35.21 ± 18.42 months, the mean age for performing the stoma closure was 65.28 ± 14.07 years, the most frequent cause for performing the stoma was malignant disease (65.85%). Risk factor for the development of incisional hernia at the stoma site after its closure was identified as a history of parastomal hernia (OR 5.90, CI95% 1.97–17.68).

Conclusions

The use of prophylactic mesh at stoma closure should be considered in patients with a history of parastomal hernia since these patients present a significantly higher risk of developing a hernia.

Predictors of morbidity related to stoma closure after colorectal cancer surgery

PURPOSE

A defunctioning stoma is essential in reducing symptomatic leakage after colorectal surgery, particularly after lower anterior resection. Subsequent stoma closure is associated with morbidity and rarely mortality. This study aimed to identify the risk factors associated with post-operative complications related to stoma closure.

METHODS

This retrospective cohort included patients who have undergone elective stoma closure between 2015 and 2017. Patient demographics, pre-morbidities, use of systemic therapy, stoma characteristics, and post-operative complications were retrieved from electronic records. Univariate and multivariate analysis was carried out to identify risk factors of stoma closure related morbidity.

RESULTS

Ninety patients were included with a median age of 65 years, of which 58 (64.4%) of them were male. Sixty-nine (76.7%) patients had loop colostomy, while the rest had loop ileostomy. Fifty-four (60%) patients received neoadjuvant or adjuvant therapy. The median time interval from stoma creation to closure was 15 months. Nineteen (21.1%) patients had post-operative complications. The two most commonly observed post-operative complications were wound complications (16.7%) and intra-abdominal collections (6.7%). Fifteen (16.7%) patients developed an incisional hernia. The median follow-up time was 29 months. There was no 30-day mortality in this cohort. In multivariate analysis, adjuvant chemotherapy was associated with a higher risk of wound complications (p = 0.027). Higher risk of incisional hernia was seen in patients with history of hypertension (p = 0.046), use of adjuvant chemotherapy (p = 0.042) and stoma-related complications before closure (p = 0.002). Male patients might be associated with a higher risk of incisional hernia.

CONCLUSION

Adjuvant chemotherapy is associated with a higher risk of post-operative complications, particularly with wound complications. Male patients, hypertension, adjuvant chemotherapy, and stoma-related complications are associated with a higher risk of incisional hernia.

Protective Loop Ileostomy Closure Techniques: Comparison of Three Different Surgical Techniques

Objective

Anastomotic leaks can be very dangerous in colorectal cancers. Protective loop ileostomy is life-saving in low anterior rectal tumors to prevent pelvic sepsis. The aim of this study is to compare early morbidities for stapled, handsewn closure (end to end) or handsewn closure (anterior wall only) of loop ileostomy, and to further assess efficacy and safety for each technique. 

Methods

Patients who underwent loop ileostomy closure from January 2014 and December 2019 retrospectively were analyzed. Multivariate logistic regression was used to determine the effect of the potential risk factors on the rate of each complication. The patients were divided into three groups based on the anastomoses. The first group included patients who had handsewn anterior closure; the second group included patients who had side-to-side anastomosis using linear stapler, and the third group included patients who had end-to-end handsewn anastomosis. The primary endpoint of the study was the postoperative 30 days. IBM Statistical Package for the Social Sciences (SPSS), version 22.0 (SPSS Inc., Chicago, IL) was used for statistical analysis.

Results

A total of 198 patients underwent reversal. There was a statistical difference between the handsewn anterior wall and stapler anastomosis in terms of postoperative ileus and wound infection. The handsewn group was superior to anastomosis with stapler (p: 0.027 and p: 0.042, respectively). A statistical difference was found between handsewn anterior wall closure and handsewn end-to-end anastomosis in terms of postoperative ileus, wound infection, and postoperative hospital stay (p: 0.013, p: 0.037, and p: 0.046, respectively). When stapled anastomosis and handsewn end-to-end anastomosis techniques were compared, a statistical difference was found in terms of postoperative ileus risk (p: 0.043), but no significant difference was found in terms of postoperative wound infection and hospital stay.

Conclusions

There was no significant difference in the rate of anastomotic leakage between the handsewn and stapled techniques. The rate of small-bowel obstruction was higher in the handsewn group. As a result, in this study, it was revealed that the handsewn anterior wall closure technique is the best among all ileostomy closure techniques.

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

AIMS

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

RESULTS

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

CONCLUSION

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

Incidence and risk factors for incisional hernia after temporary loop ileostomy closure: choosing candidates for prophylactic mesh placement

OBJECTIVES

The primary aim of this study was to identify the incisional hernia rate after temporary loop ileostomy closure. Secondary outcomes were determining the risk factors linked to this incisional hernia, which could improve the patient selection for mesh prophylaxis.

METHODS

Retrospective cohort study of all consecutive patients with temporary loop ileostomy reversal through a peristomal incision from 1st January 2011 to 1st January 2017 at our centre. Data were extracted from electronic clinical records: baseline patient characteristics, surgical factors and postoperative events. CT scans performed during follow-up were precisely analysed. Survival analysis was applied to identify risk factors for hernia development.

RESULTS

129 patients were analysed of whom 15 (11.6%) developed an incisional hernia at previous ileostomy site. The median time for incisional hernia development was 11 months (IQR = 7-21) and the median follow-up time was 37 months (IQR = 22-57). The identified patient risk factors for hernia development in survival analysis were female sex, older age, higher Body Mass Index, clinically significant parastomal hernia, clinically detectable midline incisional hernia and major postoperative complications ranked as Clavien-Dindo grade III and IV.

CONCLUSIONS

Incisional hernia after temporary loop ileostomy is a relevant problem that affects at least one in every ten patients. The previously cited risk factors might favour its development, therefore the use of a prophylactic mesh should be considered in those high-risk patients.