Comparison of different modalities for the diagnosis of parastomal hernia: a systematic review

Management of adult intestinal stomas: The 2023 French guidelines

AIM

Digestive stoma are frequently performed. The last French guidelines have been published twenty years ago. Our aim was to update French clinical practice guidelines for the perioperative management of digestive stoma and stoma-related complications.

METHODS

A systematic literature review of French and English articles published between January 2000 and May 2022 was performed. Only digestive stoma for fecal evacuation in adults were considered. Stoma in children, urinary stoma, digestive stoma for enteral nutrition, and rare stoma (Koch, perineal) were not included.

RESULTS

Guidelines include the surgical landmarks to create digestive stoma (ideal location, mucocutaneous anastomosis, utility of support rods, use of prophylactic mesh), the perioperative clinical practice guidelines (patient education, preoperative ostomy site marking, postoperative equipment, prescriptions, and follow-up), the management of early stoma-related complications (difficulties for nursing, high output, stoma necrosis, retraction, abscess and peristomal skin complications), and the management of late stoma-related complications (stoma prolapse, parastomal hernia, stoma stenosis, late stoma retraction). A level of evidence was assigned to each statement.

CONCLUSION

These guidelines will be very useful in clinical practice, and allow to delete some outdated dogma.

Development and pilot testing of a patient-reported outcome measure to assess symptoms of parastomal hernia

AIM

The aim was to develop and pilot a patient-reported outcome measure (PROM) to assess symptoms of parastomal hernia (PSH).

METHODS

Standard questionnaire development was undertaken (phases 1-3). An initial list of questionnaire domains was identified from validated colorectal cancer PROMs and from semi-structured interviews with patients with a PSH and health professionals (phase 1). Domains were operationalized into items in a provisional questionnaire, and 'think-aloud' patient interviews explored face validity and acceptability (phase 2). The updated questionnaire was piloted in patients with a stoma who had undergone colorectal surgery and had a computed tomography scan available for review. Patient-reported symptoms were examined in relation to PSH (phase 3). Three sources determined PSH presence: (i) data about PSH presence recorded in hospital notes, (ii) independent expert review of the computed tomography scan and (iii) patient report of being informed of a PSH by a health professional.

RESULTS

For phase 1, 169 and 127 domains were identified from 70 PROMs and 29 interviews respectively. In phase 2, 14 domains specific to PSH were identified and operationalized into questionnaire items. Think-aloud interviews led to three minor modifications. In phase 3, 44 completed questionnaires were obtained. Missing data were few: 5/660 items. PSH symptom scores associated with PSH presence varied between different data sources. The scale with the most consistent differences between PSH presence and absence and all data sources was the stoma appearance scale.

CONCLUSION

A PROM to examine the symptoms of PSH has been developed from the literature and views of key informants. Although preliminary testing shows it to be understandable and acceptable it is uncertain if it is sensitive to PSH-specific symptoms and further psychometric testing is needed.

Surgical management of ostomy complications: a MISSTO-WSES mapping review

BACKGROUND

The creation of an ileostomy or colostomy is a common surgical event, both in elective and in emergency context. The main aim of stoma creation is to prevent postoperative complications, such as the anastomotic leak. However, stoma-related complications can also occur and their morbidity is not negligible, with a rate from 20 to 70%. Most stomal complications are managed conservatively, but, when this approach is not resolutive, surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management of the main early and late ostomy complications: stoma necrosis, mucocutaneous separation, stoma retraction, stoma prolapse, parastomal hernia, stoma stenosis, and stoma bleeding.

MATERIAL AND METHODS

A complete literature research in principal databases (PUBMED, EMBASE, SCOPUS and COCHRANE) was performed by Multidisciplinary Italian Study group for STOmas (MISSTO) for each topic, with no language restriction and limited to the years 2011-2021. An international expert panel, from MISSTO and World Society of Emergency Surgery (WSES), subsequently reviewed the different issues, endorsed the project, and approved the final manuscript.

CONCLUSION

Stoma-related complications are common and require a step-up management, from conservative stoma care to surgical stoma revision. A study of literature evidence in clinical practice for stoma creation and an improved management of stoma-related complications could significantly increase the quality of life of patients with ostomy. Solid evidence from the literature about the correct management is lacking, and an international consensus is needed to draw up new guidelines on this subject.

Parastomal Hernia Repair

Parastomal hernias (PHs) are common and contribute to significant patient morbidity. Despite 45 years of evolution, mesh-based PH repairs continue to be challenging to perform and remain associated with high rates of postoperative complications and recurrences. In this article, the authors summarize the critical factors to consider when evaluating a patient for PH repair. The authors provide an overview of the current techniques for repair, including both open and minimally invasive approaches. The authors detail the mesh-based repair options and review the evidence for choice of mesh to use for repair.

Parastomal hernia: an overview

Parastomal hernia (PH) is one of the most frequent ostomy complications, and the reported incidence in the literature is highly variable. As highlighted by the Association of Stoma Care Nurses UK, this complication develops mainly in children and older men over 70, but many predisposing factors are related to the individual patient and surgery. There is no standardised system for assessing PH. The main assessment techniques include objective examination, ultrasound scan and computed tomography. Prevention is based on various interventions by surgeons and stoma care nurses (SCNs). The SCN's primary interventions include accurate patient evaluation, pre-operative ostomy siting, education about body weight management and advice on appropriate exercises. The treatment of PH can be conservative or surgical, and the choice is based on the patient's clinical condition. Ostomy can significantly impact on a patient's quality of life (QoL), and the presence of PH can further aggravate the situation. This overview of PH considers the incidence, aetiology, prevention, treatment and impact on QoL.

Surgical management of parastomal hernia following radical cystectomy and ileal conduit: A french multi-institutional experience

BACKGROUND

Parastomal incisional hernia (PH) is a frequent complication following the creation of an ileal conduit (IC), and it can be a significant detriment to quality of life. The aim of this study was to evaluate outcomes of PH repair following IC for urinary diversion.

METHOD

A multicenter retrospective study was conducted of 6 academic hospitals in France. The study's population included patients who underwent surgical treatment for parastomal hernia following IC creation from 2013 to 2021.

RESULTS

Fifty-one patients were included in the study. Median follow up was 15.3 months. Eighteen patients presented with a recurrence (35%), with a median time to recurrence of 11.1 months. The vast majority of PH repair was performed through an open approach (88%). With regard to technique, Keyhole was the most reported technique (46%) followed by Sugarbaker (22%) and suture only (20%). The Keyhole technique was associated with a higher risk of recurrence compared to the Sugarbaker technique (52% vs 10%, p = 0.046). Overall, there was a 7.8% rate of major complications without a statistical difference between PH repair techniques for major complications.

CONCLUSION

Surgical treatment of parastomal hernia following IC was associated with a high risk of recurrence. Novel surgical approaches to PH repair should be considered.

Parastomal hernia prevention with permanent mesh in end colostomy: failure with late follow-up of cohorts in three randomized trials

PURPOSE

Short-term results have been reported regarding parastomal hernia (PH) prevention with a permanent mesh. Long-term results are scarce. The objective was to assess the long-term PH occurrence after a prophylactic synthetic non-absorbable mesh.

METHODS

Long-term data of three randomized controlled trials (RCTs) were collected. The primary outcome was the detection of PH based exclusively on a radiological diagnosis by computed tomography (CT) performed during the long-term follow-up. The Kaplan-Meier method was used for the comparison of time to diagnosis of PH according to the presence of mesh vs. no-mesh and the technique of mesh insertion: open retromuscular, laparoscopic keyhole, and laparoscopic modified Sugarbaker.

RESULTS

We studied 121 patients (87 men, median age 70 years), 82 (67.8%) of which developed a PH. The median overall length of follow-up was 48.5 months [interquartile range (IQR) 14.4-104.9], with a median time until PH diagnosis of 17.7 months (IQR 9.3-49.0). The survival analysis did not show significant differences in the time to development of a PH according to the presence or absence of a prophylactic mesh neither in the overall study population (log-rank, P = 0.094) nor in the groups of each technique of mesh insertion, although according to the surgical technique, a higher reduction in the appearance of PH for the open retromuscular technique was found (log-rank, P = 0.001).

CONCLUSION

In the long-term follow-up placement of a non-absorbable synthetic prophylactic mesh in the context of an elective end colostomy does not seem effective for preventing PH.

Parastomal hernia after radical cystectomy with ileal conduit diversion: a narrative review

Radical cystectomy (RC) with ileal conduit urinary diversion has become a common surgical procedure. Stomal complications and particularly parastomal hernia (PH) are the most frequent complications and causes of reintervention after RC with ileal conduit urinary diversion. PH is usually asymptomatic. When PH increases in size and becomes symptomatic, it clearly impairs patients' quality of life in terms of physical limitation, mental distress and social interaction. The aim of this article was to review the current knowledge on PH after RC with ileal conduit urinary diversion, regarding its natural history, risk factors, prevention and surgical management. There is no strong recommendation on the ideal surgical technique for repair of PH after RC, but laparoscopic Sugarbaker or Sandwich techniques with non-absorbable meshes are emerging as the preferred modern means of PH repair. Techniques for prevention and repair of PH after RC need to be specifically evaluated in future prospective studies.

Prophylactic funnel mesh to prevent parastomal hernia in permanent end colostomy: A retrospective cohort study

AIM

This study assessed the impact of a prophylactic, 3D funnel-shaped intraperitoneal mesh on the rate of parastomal hernia after abdominoperineal rectum resection with permanent end colostomy.

METHODS

Data from 76 patients receiving permanent end colostomy after abdominoperineal rectum resection between 2013 and 2018 were collected retrospectively. Occurrences of parastomal hernia and reoperation rate due to parastomal hernia in patients with and without a prophylactic mesh were compared by univariate, multivariate, and propensity score-adjusted analyses.

RESULTS

Twenty-two (28.9%) of the 76 included patients received a prophylactic mesh. The mean follow-up was 39.3 ± 23.8 months. Mesh implantation reduced the incidence of parastomal hernia to 9.1% (n = 2) compared to 42.6% (n = 23) in patients without a prophylactic mesh. The propensity score-adjusted hazard ratio (HR) was 0.14 (95% confidence interval (CI): 0.04-0.48, p = 0.001). No reoperations due to parastomal hernia were needed in patients who received a prophylactic mesh, while nine patients without mesh (16.7%) required parastomal hernia repair (HR = 0.09, 95% CI: 0.00-1.76, p = 0.015). Mesh implantation was not associated with increased short-term morbidity (Clavien-Dindo grade > 2, 31.8% vs. 40.7%, p = 0.468) or 30-day mortality (4.5% vs. 3.8%, p = 1.000).

CONCLUSIONS

Prophylactic implantation of a 3D funnel-shaped intraperitoneal mesh is a safe and effective method to prevent parastomal hernia in patients requiring permanent end colostomy. Mesh placement significantly reduces reoperations due to parastomal hernia.

The role of radiological classification of parastomal hernia as a predictor of the need for surgical hernia repair: a retrospective cohort study

PURPOSE

Parastomal hernia (PSH) is a frequent complication of stoma creation during colorectal surgery. Radiological classification systems have been proposed for PSH but are primarily used for research. Our objective was to determine if PSH radiological classification at diagnosis could predict the need for surgical repair during follow-up.

METHODS

In this retrospective cohort study, we reviewed 705 postoperative CT scans from 154 patients with permanent stoma creation from 2015 to 2018. Patients were included for analysis if a primary PSH was diagnosed on any exam. PSH were classified according to the European Hernia Society (EHS) and Moreno-Matias (MM) classification systems.

RESULTS

The incidence of radiological PSH was 41% (63/154) after a median radiological follow-up of 19.2 months (interquartile range, 10.9-32.9). Surgical repair was required in 17 of 62 patients with a primary PSH. There was no significant correlation between PSH classification and surgical hernia repair for either the EHS (p = 0.56) or MM classification systems (p = 0.35) in a univariate analysis. However, in a multivariate analysis, the type of PSH according to the EHS classification was significantly correlated with PSH repair during follow-up (p = 0.02). Type III PSH were associated with a lower incidence of surgical hernia repair as compared with type I, with a hazard ratio (HR) of 0.01 (95% CI, <0.00-0.20). A similar correlation was not seen using the MM classification (p = 0.10).

CONCLUSION

EHS classification of PSH was significant correlated with the need for surgical repair during short-term follow-up. Prospective studies are required to establish a potential role in patient care.

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.

Parastomal gallbladder herniation: A case report and review of the literature

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Gallbladder herniation is a rare complication of a parastomal hernia, affecting primarily elderly females.

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For patients with parastomal swelling and pain gallbladder herniation should be included in the differential diagnosis.

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Elderly patients with multiple comorbidities may benefit from a conservative approach instead of surgery.

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The use of prophylactic mesh when creating a permanent end colostomy reduces the rate of parastomal hernias.

Introduction

Parastomal hernia is a common complication of patients living with an enterostomy. However, a parastomal hernia involving the gallbladder is a rare condition with only eight cases documented in the literature.

Presentation of case

We report the case of a 69-year old female who underwent an open right hemicolectomy with creation of a colostomy and terminal ileostomy. She presented with parastomal swelling and pain 16 months later. A computed tomography scan revealed a parastomal herniation of the gallbladder. We elected to proceed with a cholecystectomy and hernia repair, the patient was asymptomatic at her last follow-up.

Discussion

A systematic search of the literature found eight previously published cases. This condition primarily affects elderly females. Five patients were treated surgically and three conservatively, all with a favorable outcome. In frail patients without complicating factors, a conservative treatment approach with surveillance may be safe. We chose a surgical approach due to the symptomatic nature of the presentation and the gallstone containing hernia. This is the first case of a parastomal gallbladder herniation containing a large gallstone.

Conclusion

This report should help broadening the physician’s differential diagnosis in dealing with patients with symptomatic parastomal hernias and provide an example for diagnosis and management of this complication.