A new stomaplasty ring (Koring™) to prevent parastomal hernia: an observational multicenter Swiss study

Use of prophylactic mesh during initial stoma creation to prevent parastomal herniation: a systematic review and meta-analysis of randomised controlled trials

AIM

Parastomal hernia (PSH) is a common complication following stoma creation. Previous reviews found mesh reinforcement during initial stoma creation beneficial in reducing PSH incidence. Since then, several multicentre randomised controlled trials (RCTs) produced widely ranging results rendering previous findings debatable. This current review assessed whether combining the latest larger multicentre RCTs would alter the previous findings.

METHODS

The Cochrane Library, MEDLINE and Embase were searched from the respective dates of inception until 15 January 2021. RCTs were included if they compared mesh with no mesh during initial stoma creation in adult patients to prevent PSH. Included RCTs were summarised narratively and meta-analysed to estimate the relative risk (RR) of PSH incidence (primary analysis), peristomal complications and PSH repair (secondary analyses). Several subgroup analyses were performed, including mesh type (synthetic/biologic), surgical technique (open/laparoscopic) and mesh position (sublay/intraperitoneal).

RESULTS

Thirteen RCTs were included in the primary meta-analysis (1070 patients); PSH incidence was reduced in patients with mesh compared with patients without mesh at maximal follow-up (RR = 0.54; 95% CI 0.39-0.77; I²  = 67%; P < 0.01). The number of PSH repairs was fewer in patients who had mesh (RR = 0.63; 0.35-1.14; I²  = 6%; P = 0.39), with no difference in peristomal complications (RR = 0.96; 0.55-1.70; I²  = 0%; P = 0.71), comparing with no mesh. Subgroup analyses suggested that placing synthetic mesh using an open sublay technique might be more beneficial.

CONCLUSIONS

Prophylactic mesh reinforcement during initial stoma creation reduces PSH incidence and potentially its repair, without an increase in peristomal complications. However, substantial heterogeneity among included RCTs limits confidence in the results.

Do North American colorectal surgeons use mesh to prevent parastomal hernia? A survey of current attitudes and practice

Background

The use of prophylactic mesh in end colostomy procedures has been shown to reduce the rate of parastomal hernia. However, the degree to which the practice has been adopted clinically remains unknown. We conducted a study to evaluate the current opinions and practice patterns of Canadian and US colorectal surgeons with regard to the use of prophylactic mesh in end colostomy.

Methods

Between May and July 2017, we conducted an internet-based survey of colorectal surgeons in Canada and the United States (selected at random). Using a questionnaire designed and tested for this study, we assessed the rate of mesh use, types of mesh and placement techniques, and perceived barriers and facilitators associated with the practice.

Results

Forty-eight (51.6%) of 93 invited Canadian surgeons and 253 (16.6%) of 1521 invited US surgeons responded (overall response rate 18.6%). Of the 301 respondents, 32 (10.6%) were currently using mesh, 32 (10.6%) had previously used mesh, and 237 (78.7%) had never used mesh. Of 29 respondents currently using mesh, 12 (41.4%) used it only in selected patients; the majority used a sublay technique (20 [69.0%]) and biologic mesh (17 [58.6%]). Most respondents agreed that parastomal hernias are common and negatively affect quality of life; however, there remained concerns about evidence quality and the perceived risk associated with mesh among those who had never or had previously used mesh.

Conclusion

Prophylactic mesh placement remains relatively uncommon; when used, biologic mesh was the most common type. Many surgeons were not convinced of the safety or efficacy of prophylactic mesh placement.

The Longtan Modification: An Effective and Economical Surgical Innovation for Parastomal Hernia Post-Intraperitoneal Sigmoidostomy

PURPOSE

This study was designed to introduce a new surgical innovation, referred to as the "Longtan modification," for cases with parastomal hernia (PSH) following intraperitoneal sigmoidostomy, and to assess the safety and feasibility of this procedure.

METHODS

Between January 2013 and June 2016, a total of 26 consecutive cases with PSH successfully underwent this procedure. The patient demographics, surgical outcomes, stoma-related complications, and the stoma function were collected and analyzed.

RESULTS

Mean diameter of the hernia ring was 7.6 cm, mean operation time was 94.2 minutes, and mean intraoperative blood loss was 18.0 mL. The mean period of postoperative hospitalization was 4.4 days while the mean hospitalization cost was only $3,750 USD. There were no severe complications such as postoperative hemorrhage, ischemic necrosis, peritoneal infection, or intestinal obstruction, although one case suffered from postoperative infection at the site of incision. None of the cases had a recurrence of PSH during the follow-up period. In addition, the stoma functioned efficiently and appropriately following the Longtan modification.

CONCLUSION

Overall, the Longtan modification appears to be an effective and economical surgical innovation for cases with PSH following intraperitoneal sigmoidostomy.

Meta-analysis of prophylactic mesh to prevent parastomal hernia

BACKGROUND

Rates of parastomal hernia following stoma formation remain high. Previous systematic reviews suggested that prophylactic mesh reduces the rate of parastomal hernia; however, a larger trial has recently called this into question. The aim was to determine whether mesh placed at the time of primary stoma creation prevents parastomal hernia.

METHODS

The Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL were searched using medical subject headings for parastomal hernia, mesh and prevention. Reference lists of identified studies, clinicaltrials.gov and the WHO International Clinical Trials Registry were also searched. All randomized clinical trials were included. Two authors extracted data from each study independently using a purpose-designed sheet. Risk of bias was assessed by a tool based on that developed by Cochrane.

RESULTS

Ten randomized trials were identified among 150 studies screened. In total 649 patients were included in the analysis (324 received mesh). Overall the rates of parastomal hernia were 53 of 324 (16·4 per cent) in the mesh group and 119 of 325 (36·6 per cent) in the non-mesh group (odds ratio 0·24, 95 per cent c.i. 0·12 to 0·50; P < 0·001). Mesh reduced the rate of parastomal hernia repair by 65 (95 per cent c.i. 28 to 85) per cent (P = 0·02). There were no differences in rates of parastomal infection, stomal stenosis or necrosis. Mesh type and position, and study quality did not have an independent effect on this relationship.

CONCLUSION

Mesh placed prophylactically at the time of stoma creation reduced the rate of parastomal hernia, without an increase in mesh-related complications.