A semi-Markov model comparing the lifetime cost-effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing end colostomy creation for rectal cancer

Risk factors and timing of incisional hernia development following ostomy reversal: a retrospective analysis

INTRODUCTION

Former stoma-site incisional hernia (FSH) is a common complication after ostomy reversal, with a variable reported incidence of up to 50%. Current literature suggests that FSH is underreported due to the lack of a definitive understanding of the timeline of its occurrence and recurrence, making FSH prevention a clinical dilemma. This study identifies FSH risk factors and diagnostic timeline to aid surgeons' clinical decision-making.

METHODS

A retrospective chart review was conducted on 340 patients who underwent ostomy reversal between January 1, 2016, and December 31, 2021. Data collected include demographics, medical history, course of ostomy treatment, and hernia diagnosis. Logistic regression and Kaplan-Meier analysis were used to identify risk factors and understand the timeline of hernia occurrence.

RESULTS

The total incidence of hernia, including patients who had a parastomal hernia before ostomy reversal, FSH after reversal, or both, was 38.8%. The incidence of former stoma-site hernia alone was 24.4%. Significant risk factors identified were elevated BMI, presence of parastomal hernia, hypertension, diabetes, immunosuppression, and the emergency nature of the case. Kaplan-Meier analysis showed that patients with either parastomal hernia prior to ostomy reversal or obesity had a greater than 35% likelihood of being diagnosed with FSH within the first 2 years following reversal. Other risk factors, including chemotherapy, radiation therapy, ostomy history, hernia history, smoking, and type of ostomy, lacked significance. The median time between ostomy reversal and the first FSH diagnosis was 295 days, and 84.3% of the cases were diagnosed within the first 2 years.

CONCLUSION

Patients with ostomy are at substantial risk of developing FSH throughout the entire span of ostomy treatment. Patients with a high BMI, a parastomal hernia before ostomy closure, diabetes, and hypertension are at even higher risk of developing FSH.

Initial and recurrent management of parastomal hernia after cystectomy and ileal conduit urinary diversion: a 10 year single-center experience

PURPOSE

The management of parastomal hernia following cystectomy and ileal conduit diversion is challenging due to its specific nature and a high recurrence rate, yet is poorly described.

METHODS

We retrospectively searched the clinical data warehouse of our center for patients who had primary parastomal hernia repair following cystectomy and ileal conduit diversion. The primary endpoint was recurrence of parastomal hernia; secondary endpoints were postoperative complications and surgical management of recurrences.

RESULTS

From January 1st 2012 to January 1st 2022, 35 patients were included in the study, 13 patients (37.1%) were operated with the Keyhole technique and 22 patients (62.9%) with the Sugarbaker technique. The median follow-up was 24 months. The main complication was urinary tract infection, in 6 patients (17.4%). Postoperative complications were severe in 4 patients (11.4%), 3 (8.6%) for prosthesis extraction due to infection. Ninety-day mortality was null. Eight patients (22.9%) had a symptomatic recurrence of parastomal hernia leading to a second surgery, 4 patients (30.7%) in the Keyhole group and 4 patients (18.2%) in the Sugarbaker group. Surgical management of recurrences involved repair without synthetic mesh in 4 patients (50%) due to difficult adhesiolysis, leading to a third surgery for 3 patients (37.5%).

CONCLUSION

The high rates of recurrence observed with the Keyhole technique, in particular, but also with the Sugarbaker technique, suggest that these techniques should no longer be used for the repair of parastomal hernia after ileal conduit urinary diversion. New preventive and curative approaches need to be explored to improve the surgical management of parastomal hernia.

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.

EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation

Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.

Evaluating the cost-utility of intravesical Bacillus Calmette-Guérin versus radical cystectomy in patients with high-risk non-muscle-invasive bladder cancer in the UK

AIMS

Approximately 75% of bladder cancer (BC) cases present as non-muscle-invasive BC (NMIBC). In patients with high-risk NMIBC, the mainstay treatment is intravesical Bacillus Calmette-Guérin (BCG), with immediate radical cystectomy (RC) as an alternative treatment option. The aim of the present study was to evaluate the cost-utility of BCG versus RC in patients with high-risk NMIBC from the UK healthcare payer perspective.

MATERIALS AND METHODS

A six-state Markov model was developed that covered controlled disease, recurrence, progression to muscle-invasive BC, metastatic disease, and death. The model included adverse events of BCG and RC and monitoring and palliative care. Drug costs were obtained from the British National Formulary. Intravesical delivery, RC, and monitoring costs were sourced from the National Tariff Payment System and the literature. Utility data were obtained from the literature. Analyses were run over a 30-year time horizon, with future costs and effects discounted at 3.5% per annum. One-way and probabilistic sensitivity analyses were performed.

RESULTS

The base case analysis comparing BCG with RC showed that BCG would increase life expectancy by 0.88 years versus RC, from 7.74 to 8.62 years. BCG resulted in an increase of 0.76 quality-adjusted life years (QALYs) versus RC, from 5.63 to 6.39 QALYs. Patients incurred lower lifetime costs if treated with BCG (£47,753) than with RC (£64,264). Cost savings were mainly driven by the lower cost of BCG versus RC, and palliative care costs. Sensitivity analyses showed that results were robust to assumptions.

LIMITATIONS

The evidence base informing efficacy estimates of BCG is heterogeneous as different BCG administration schedules were reported in the literature, while incidence and cost data on some BCG-associated adverse events were sparse.

CONCLUSIONS

Intravesical BCG led to increased QALYs and reduced costs versus RC for patients with high-risk NMIBC from the UK healthcare payer perspective.

Cost Effectiveness of the Use of Prophylactic Mesh To Prevent Parastomal Hernia After Urinary Diversion with an Ileal Conduit

Background

Prophylactic lightweight mesh in the sublay position reduced the cumulative incidence of parastomal hernia (PSH) after cystectomy with ileal conduit diversion in a randomised controlled trial.

Objective

To investigate whether the use of prophylactic mesh is cost-effective in comparison to no mesh from the health care provider perspective.

Design, setting, and participants

Data on health care resource utilisation (outpatient care and inpatient care) were obtained for 159 patients included in a randomised trial. The patients underwent surgery at Skåne University Hospital or Helsingborg County Hospital (80 with a prophylactic mesh and 79 without) and information about care was ascertained from the regional health care register. The patients underwent surgery between 2012 and 2017 and were followed until death or August 2020.

Outcome measurements and statistical analyses

The primary outcome measure was the clinical incidence of PSH. Costs are reported in Euro in 2020 prices (€1 = 10.486 Swedish Krona) and presented as the incremental cost-effectiveness ratios (ICERs) with confidence intervals (CIs) calculated using a nonparametric bootstrap procedure. Sensitivity analyses and subgroup analyses were performed to capture the uncertainty for ICERs.

Results and limitations

The mean difference in total costs between the mesh and no-mesh groups was −€2047 (95% CI −€16 441 to €12 348). Seventeen patients (21.5%) in the no-mesh group developed clinical PSH versus six patients (7.5%) in the mesh group (p = 0.001). This indicates that mesh is less costly and more effective compared to no mesh from the health care provider perspective. Subgroup analyses showed that results were more advantageous for women and for patients younger than 71 yr and with less comorbidity than for their counterparts.

Conclusions

The use of prophylactic mesh during ileal conduit reconstruction to prevent PSH is cost-effective from the health care provider perspective.

Patient summary

In patients having their bladder surgically removed, a mesh implant can be inserted when a portion of the intestine is used to create an opening to drain urine from the body. Our results show that mesh use to prevent development of a hernia at the opening where urine exits the body is cost-effective from the perspective of health care providers.