Outcomes of parastomal hernia repair after national centralization

Outcomes after surgical repair of primary parastomal hernia

PURPOSE

Parastomal hernia is a frequent complication after stoma construction, with increasing incidence over time. Surgical repair is reported with a high recurrence rate and the evidence on the topic is limited. We conducted a retrospective study to evaluate the incidence of recurrence after parastomal hernia repair and assessed the risk factors and predictors for recurrence at the Regional Hernia Center at Horsens Regional Hospital, Denmark.

METHODS

119 patients underwent primary parastomal hernia repair from January 2017 until April 2021. Mean follow-up period was 72 months. Information including demographic data, non-modifiable risk factors and modifiable risk factors were assessed and analyzed using LASSO to select relevant predictors and GLM was employed hereafter.

RESULTS

Multivariate analysis showed that age, diabetes, IBD, constipation, and fecal incontinence were strong pre-operative predictors, with age, IBD, ileostomy, and colorectal cancer also reaching significance in univariate analyses. Post-operatively, EHS classification 1, and Clavien Dindo Grade 3b were identified as strong predictors in univariate analyses.

CONCLUSION

Recurrence after parastomal hernia repair was 17.64% during a follow-up period of minimum 3.5 years.

Acute Parastomal Hernia Presentations: A 10-Year Review of Management and Outcomes

Introduction

The acute presentation of parastomal hernia (PSH) can range from exacerbation of pain to life-threatening incarceration. Managing the acute PSH is challenging, particularly in the presence of concomitant midline incisional hernia. Most literature focuses on the outcomes of elective PSH repair. There is a paucity of literature on optimal management approaches to emergency PSH presentations. We aim to evaluate the outcomes of management of acute PSH presentations at a large acute tertiary hospital over a 10-year-period.

Methods

A retrospective analysis performed from May 2013 - May 2023 for all acute parastomal hernia presentations. The data collated included: demographics, index operation/pathology, duration of the stoma, clinical presentation, laboratory and imaging results and management outcomes (non-operative vs. operative intervention).

Results

Twenty-two admissions of acute PSH over the study period with the median age of 77 years, and 14 males. The median Charlson comorbidity score was 5. Most patients had stoma formation due to malignancy (12) with most end-colostomy (10). 11 patients had previous PSH repairs. 13 patients underwent operative intervention on index presentation via a combination of approaches. 4 required small bowel resection and 4 had resection of stoma; 4 had relocation of the stoma. There was one postoperative death due to sepsis related multi-organ failure. There were five recurrences of PSH on follow-up. Of the nine patients managed non-operatively, seven subsequently had elective reconstruction.

Conclusion

Acute PSH presentation usually requires operative intervention with considerable recurrence rates. The approach to the PSH repair, in the acute setting, needs to be individualised. Further study is required to assist with the development of guidelines for managing this difficult problem.

Robotic Pauli repair of parastomal hernia

BACKGROUND

Robotic retro-muscular mesh repair of parastomal hernia (PH) is possible with transversus abdominis release. The aim of this study is to report mid-term results with this method.

METHODS

Patients who underwent surgery for PH were enrolled in a prospective study. Patients with concomitant midline hernia also underwent Rives repair. Polypropylene meshes with an absorbable buffer mesh were used in the retro-muscular pocket-except PTFE was chosen for inflammatory bowel disease patients. Follow-up was by telephone and physical examination and CT if suspicion of complication.

RESULTS

Of the 56 included ostomy patients, 44 had colostomies, 10 had ileostomies, and two had urostomies. Thirty-nine percent had a concomitant hernia, and 25% had recurrent PH. The mean operating time without accessory repair was 156 min (SD 37), and with accessory repairs 220 min (SD 62). One bowel lesion and one vascular injury to the stoma occurred, prompting intraoperative stoma revision without postoperative morbidity. Postoperative complications ensued in 12 patients (23%). One patient had stoma necrosis after 3 weeks and the stoma was relocated. One patient had a mesh infection, 3 patients temporary ileus, one patient hypovolemic renal failure, and two patients experienced a flare-up of their Crohn's Disease. One parastomal abscess was drained percutaneously. The median postoperative stay was 3 days (1-21; mean 3.7 days), and the readmission rate was 8.9%. The recurrence rate at mean and median 24 months follow-up is 5.4%, two in ileostomy patients and one colostomy patient with unaltered bulging where CT shows a relatively large prolapse and recorded as a failure.

CONCLUSION

Robotic Pauli repair has shown promising results. However, repair fails of PH at small bowel ostomies with short mesentery. ePauli/TAR is now the preliminary choice for eligible patients at our site. Comparative studies with the intraperitoneal mesh standard are needed.

Comparison of the 3-D mesh and Sugarbaker repair for parastomal hernia: a single center experience in China

Parastomal hernias (PSH) are difficult to manage and associated with high rates of postoperative recurrence and complications. Sugarbaker and three-dimensional (3-D) mesh repair are commonly used methods for the surgical treatment of PSH. However, the efficacy and safety of these surgical techniques have not been adequately compared. Patients with PSH who received 3-D mesh or Sugarbaker repair at our center from August 2012 to May 2023 were included. We retrospectively analyzed their demographic data and postoperative outcomes. The primary outcome measure was the recurrence rate at 1-year follow-up. A total of 86 patients were enrolled, involving 53 in the 3-D mesh (62%) group and 33 in the Sugarbaker (38%) group. Most cases (73%) involved were the laparoscopic approach. The recurrence rate at 1-year follow-up was 15% (eight cases) in the 3-D mesh group and 24% (eight cases) in the Sugarbaker group, with no statistical significance (P = 0.29). Additionally, no differences were observed between the 3-D mesh and Sugarbaker groups in the length of hospitalization or in short- and long-term complications. Sugarbaker and 3-D mesh repair have similar clinical efficacy in the surgical treatment of PSH. Further randomized controlled trials are required to confirm these results.Trial registration number.This study was retrospectively registered at clinicaltrials.gov (NCT06077318).

Repair of parastomal hernia after Bricker procedure: retrospective consecutive experience of a tertiary center

BACKGROUND

Ileal conduit parastomal hernias (ICPHs) are frequent after radical cystectomy with ileal conduit urinary diversion, but their management is debated. This study aimed to review the results of ICPH repair according to Sugarbaker or Sandwich techniques, with special interest in ICPH recurrence and urological complications.

METHODS

The authors reviewed a consecutive series of patients undergoing ICPH repair between January 2014 and December 2020. Primary endpoints were ICPH recurrences at clinical exam and cross-sectional abdominal computed tomography (CT) scans. Secondary endpoints were any other complications possibly related to the ICPH repair.

RESULTS

Twenty-three patients underwent ICPH repair surgery (16 Sugarbaker and 7 Sandwich techniques) during the study period. Sixteen patients underwent a primary laparoscopic approach. All but one patient underwent at least one abdominal CT during the follow-up. Median clinical and CT scan follow-up times were 57 and 50.5 months, respectively. Clinical and CT ICPH recurrence rates were 4.5% and 13% at 5 years, respectively. Eighteen patients (78%) suffered no urological complications during the follow-up period, but three patients (13%) needed redo surgery on the urinary ileal conduit.

CONCLUSION

The modified Sugarbaker or Sandwich techniques might be considered as promising techniques for ICPH repair with a low rate of recurrence. The urological complications, and particularly the ileal conduit-related issues, need to be evaluated in further studies. Controlled and prospective data are required to compare the Sugarbaker and Sandwich techniques to the Keyhole approach for ICPH repairs.

Management of the Difficult Stoma

Fecal ostomy creation is a commonly performed procedure with many indications. Better outcomes occur when preoperative patient education and stoma site marking are provided. Despite a seemingly simple operation, ostomy creation is often difficult and complications are common. Certain risk factors, particularly obesity, are strongly associated with stoma-related complications. The ability to optimize the ostomy and stoma in the operating room and to troubleshoot frequently encountered post-operative stoma-related issues are critical skills for surgeons and ostomy nurses alike.

Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland

BACKGROUND

In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs).

METHODS

All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis.

RESULTS

A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002).

CONCLUSION

Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.

The PROPHER study: patient-reported outcomes after parastomal hernia treatment-a prospective international cohort study

AIM

A significant proportion of stoma patients develop a parastomal hernia (PSH), with reported rates varying widely from 5% to 50% due to heterogeneity in the definition and mode of diagnosis. PSHs are symptomatic in 75% of these patients, causing a significant impact on quality of life due to issues with appliance fitting, leakage, skin excoriation and pain. They can also lead to emergency presentations with strangulation and obstruction. Evidence is lacking on how to select patients for surgical intervention or conservative treatment. In those who do undergo surgery, the best operation for a particular patient or PSH is not always clear and many options exist. The aim of this study is to assess the impact of an individual patient's PSH treatment on their subsequent self-reported outcomes including treatment success and quality of life.

METHODS

This is a prospective international cohort study of PSH treatment, including both operative and non-operative interventions. A global network of clinicians and specialist nurses will recruit 1000-1500 patients and centralize detailed information, their individual background and their PSH treatment, as well as short-term outcomes up to 30 days. Patients will then provide their own outcomes data including quality of life and whether their treatment was successful, via a secure online system, at 3, 6 and 12 months. PROPHER will be run in two phases: an internal pilot phase of at least 10 hospitals from up to five countries, and a main phase of up to 200 hospitals from across the European Society of Coloproctology network.

DISCUSSION

This study will provide a wealth of contemporaneous information which will improve our ability to counsel patients and facilitate improved selection of appropriate and personalized interventions for those with a PSH.

Outcomes of Emergency Parastomal Hernia Repair in Older Adults: A Retrospective Analysis

INTRODUCTION

Parastomal hernias are common and many are never repaired. Emergency parastomal hernia repair (PHR) is a feared complication following ostomy creation, yet the incidence and long-term outcomes of emergency PHR are unknown.

MATERIALS AND METHODS

We performed a retrospective analysis of 100% Medicare claims data (2007-2015) to evaluate complications, readmissions, reoperations, hospitalizations, and mortality after emergency PHR. We used logistic regression and Cox proportional hazard models to determine the association of surgical approach, including repair with ostomy reversal, resiting, mesh, minimally invasive approach, or a myofascial flap. Analysis took place between June 2022 and February 2023.

RESULTS

A total of 6658 patients underwent emergency PHR (mean [standard deviation] age, 75.9 [9.8] y; 4031 female individuals [60.5%]). Overall, 3433 (51.2%) patients underwent primary PHR, 1626 (24.4%) underwent PHR with ostomy resiting, and 1599 (24.0%) underwent PHR with ostomy reversal. In the 30 d after surgery, 4151 (62.3%) patients had complications and 55 (0.83%) underwent reoperation. Compared to local repair, the 30-d odds of complications were lower for patients who underwent ostomy resiting (odds ratio 0.82 [95% confidence interval 0.72-0.93]). Five y after surgery, the cumulative incidence of reoperation was 12.0% and was lowest for patients who underwent PHR with ostomy reversal (hazard ratio 0.15 [95% confidence interval 0.11-0.21]) when compared to local repair.

CONCLUSIONS

Emergency PHR is associated with significant morbidity. However, technique selection may influence outcomes. Understanding the prognosis of emergency PHR may improve decision-making and patient counseling for patients living with this common disease.

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.