Abdominal rectus muscle atrophy and midline shift after colostomy creation

ACR Appropriateness Criteria® Hernia

Abdominopelvic hernias are common clinical entities composed of a wide variety of congenital, traumatic, and iatrogenic etiologies. Any weakness in the body wall may result in hernia of cavity contents with concomitant risks of morbidity and mortality. Presentations may be specific, palpable body wall mass/bulge, or vague, nonspecific pain through bowel obstruction. This document focuses on initial imaging of the adult population with signs of symptoms prompting suspicion of abdominopelvic hernia. Imaging of the abdomen and pelvis to evaluate defects is essential for prompt diagnosis and treatment. Often CT and ultrasound are the first-line modalities to quickly evaluate the abdomen and pelvis, providing for accurate diagnoses and management of patients. MRI protocols may be useful as first-line imaging studies, especially in patients with orthopedic instrumentation. Although often performed, abdominal radiographs and fluorographic procedures may provide indirect evidence of hernias but are usually not indicated for initial diagnosis of hernia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Use of prophylactic stoma mesh is a risk factor for developing rectus abdominis muscle atrophy

Purpose

The aim of this study was to evaluate the possible risk factors for developing a parastomal hernia (PSH) in a cohort of rectal cancer patients with and without the application of a retro-muscular prophylactic mesh. The evaluated risk factors included the position of the stoma in the rectus abdominis muscle (RAM), RAM atrophy and shift of abdominal wall midline structures.

Methods

Rectal cancer patients treated with an abdominoperineal excision or Hartmann’s procedure between 2002 and 2015 at Västmanland Hospital, Sweden was included. Postoperative CT examinations were retrospectively reviewed regarding the presence of PSH and RAM atrophy and for measurements such as position of the stoma in the RAM.

Results

116 patients were included, with a median age of 71 years. 70 patients received a prophylactic stoma mesh. 55 patients (47%) had a parastomal hernia at three-year follow-up. Rectus abdominis muscle atrophy was significantly higher in the mesh group compared with the non-mesh group (37% vs 2%; P = 0.04). RAM atrophy was a significant independent protective factor for developing a PSH (P = 0.007; OR 0.15; 95% CI 0.03–0.55).

Conclusion

Placement of a prophylactic retro-muscular stoma mesh resulted in a high frequency of RAM atrophy distal to the stomal aperture and patients with such atrophy had a lower risk of developing a PSH.

Atrophic change of the abdominal rectus muscle significantly influences the onset of parastomal hernias beyond existing risk factors after end colostomy

PURPOSE

To investigate optimal risk factors, including atrophy of the abdominal rectus muscle (ARM) for postoperative parastomal hernia (PH) in patients who underwent end colostomy at left lower quadrant.

METHODS

This single-institution retrospective study included 91 patients who underwent end colostomy between April 2004 and December 2015. The surgical and long-term outcomes among patients with or without PH were collected and compared.

RESULTS

Altogether, 22 (24.2%) patients had a PH including 15 (68.2%) patients with a simultaneous incisional hernia. Univariate analysis showed that older patients (71 ± 11.9 vs. 64 ± 12.2 years, p = 0.03) and those with higher body mass index (BMI) (23.8 ± 3.8 vs. 20.9 ± 3.3 kg/m², p < 0.001) had a statistically significant relation with having PHs. Relative atrophy of left abdominal rectus muscle was more frequently found in patients with PH (ratio of left side/right side; caudal level and medial side: 0.66 vs. 0.92, p < 0.01, caudal level and lateral side: 0.95 vs. 1.03, p = 0.04). Multivariate analysis revealed that BMI > 25 kg/m² [odds ratio (OR) 9.05, 95% confidence interval (CI) 2.06-39.76, p = 0.003] and atrophy of the left lower medial portion of the abdominal rectus muscle (OR 12.85, 95% CI 2.49-66.39, p = 0.002) were independent risk factors for PHs. Neither the laparoscopic approach nor the extraperitoneal route of the colostomy was proven to correlate with a lower rate of PHs.

CONCLUSIONS

High BMI and atrophic change of ARM were significantly associated with PH development. Surgical techniques for prevention of atrophic change of ARM are expected to reduce the incidence of PHs.

Atrophy of the Rectus Abdominis After Left-Side Donor Hepatectomy: Comparison of Upper Abdominal Midline vs Mercedes Incision

OBJECTIVE

This study of living liver transplant donors compared postoperative atrophy of the rectus abdominis after an upper abdominal midline incision vs a Mercedes incision.

METHODS

A total of 110 donors underwent left-side donor hepatectomy in our hospital from 2007 to 2016. We analyzed the postoperative computed tomography data of 102 cases 3, 6, and 12 months after surgery. Donors were categorized as having a midline incision (MID group, n = 39) or a Mercedes incision (MER group, n = 63). The rectus abdominis was assessed on computed tomography images, and the percentage of muscle thickness (PMT) was compared in the 2 groups.

RESULTS

Patient age, sex, and body mass index did not differ in the 2 groups. Laparoscope-assisted hepatectomy was only performed in the MID group, while open hepatectomy was performed mainly in the MER group. The mean PMT of the rectus abdominis did not change 3, 6, and 12 months after surgery in the MID group but decreased to 80%, 76%, and 72% of the baseline value in the MER group 3, 6, and 12 months after surgery, respectively. The PMT values were significantly lower in the MER group than in the MID group at all 3 time points (P < .001). In the MER group, rectus abdominis atrophy was significantly worse on the right side than on the left. There was no significant difference in morbidity between the 2 groups.

CONCLUSION

In living donor liver transplant, the Mercedes incision resulted in significantly greater atrophy of the rectus abdominis in donors compared with the midline incision.

A pilot single-centre randomized trial assessing the safety and efficacy of lateral pararectus abdominis compared with transrectus abdominis muscle stoma placement in patients with temporary loop ileostomies: the PATRASTOM trial

AIM

Transrectal stoma placement is considered the standard technique for positioning a stoma. A prospective series using a novel method of lateral pararectal stoma placement recently revealed a remarkably low stoma herniation rate. A randomized trial was conducted to compare the lateral pararectal with the transrectal stoma position with regard to parastomal herniation, stoma-related morbidity and quality of life.

METHOD

Adult patients undergoing elective placement of a temporary loop ileostomy were eligible for inclusion. Patients were intra-operatively randomized to undergo either a lateral pararectal or a transrectal ileostomy. The primary end-point was the rate of parastomal herniation. Secondary end-points included other stoma-related complications and quality of life. Sample size calculation resulted in 54 patients having to be analysed to detect a difference of parastomal herniation of 30% with an 80% power and a 5% significance level. The trial was registered with the German Clinical Trials Register (registration number DRKS00003534).

RESULTS

Between April 2012 and April 2014, 30 patients were randomized to each group. The incidence of parastomal herniation did not differ between the lateral pararectal (5 of 27) and the transrectal group (4 of 29; P = 0.725). There was also no significant difference regarding other stoma-related complications and the EORTC quality of life scales C30 and CR29.

CONCLUSION

The incidence of parastomal herniation and other stoma-related complications did not differ between the groups. However, due to the limited sample size a small difference in favour of one of the two stoma placement techniques cannot be entirely ruled out.