CT evaluation for 'quiescent' herniation following closure of diverting loop ileostomy

An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure

PURPOSE

To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest.

METHODS

Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity.

RESULTS

Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I² 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I² 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I² 58% and 0.04 (95% CI 0.03-0.06), I² 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I² 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I² 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24).

CONCLUSION

Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.

Incisional hernia rate after ileostomy closure in lateral pararectal stoma versus transrectal stoma placement: follow-up of the randomized PATRASTOM trial

AIM

Because damage to the rectus abdominis muscle during ileostomy placement and reversal might be a risk factor for the development of stoma-site incisional hernia (SSIH), we hypothesized that positioning of the stoma lateral to the rectus abdominis muscle might prevent SSIH.

METHOD

To investigate whether a lateral pararectal stoma position lowers the incidence of SSIH in comparison with a transrectal position, a follow-up study of the PATRASTOM trial, which had randomized stoma placement (lateral pararectal versus transrectal), was conducted. All former participants were invited simultaneously for a follow-up visit in September 2016, 2 years after database closure of the PATRASTOM trial. For patients who were not able to attend the follow-up, the electronic chart as well as MRI/CT scans were reviewed with regard to the presence of SSIH.

RESULTS

Follow-up - either clinical or radiological - was available for 47 of the 60 PATRASTOM participants. The median duration of follow-up was 3.4 years (interquartile range 3.0-4.1 years). SSIH occurred in 3 of 23 patients (13.0%) in the lateral pararectal group compared with 7 of 24 patients (29.2%) in the transrectal group (P = 0.287). Four of the 10 patients diagnosed with SSIH had already undergone or were scheduled for hernia repair. Of the patient and procedure characteristics which may have an impact on the development of incisional hernia none was a significant risk factor for SSIH.

CONCLUSION

In the present follow-up study, no difference in the incidence of SSIH was found between lateral pararectal and transrectal stoma construction in an elective setting.

Systematic review and meta-analysis of incisional hernia post-reversal of ileostomy

PURPOSE

Incisional hernia following closure of loop ileostomy is a common problem. Assessment of the proportion of this complication is limited by small sample size and inconsistent reporting. The aim of this review was to provide an estimate of the proportion of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported proportion.

METHODS

A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled proportion estimates. Meta-regression models were formed to explore potential heterogeneity.

RESULTS

42 studies with 7166 patients were included. The pooled estimate of the proportion of incisional hernia after ileostomy closure was 6.1% (95% confidence interval, CI 4.4-8.3%). Proportion estimates for higher quality studies and studies reporting on incisional hernia as primary outcome were 9.0% (95% CI 6.3-12.7%) and 13.1% (95% CI 8.8-19.1%). Significant between-study heterogeneity was identified (P < 0.001, I² = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies affected the proportion.

CONCLUSION

The proportion of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported proportion.

Incidence, risk factors and prevention of stoma site incisional hernias: a systematic review and meta-analysis

AIM

Stoma reversal might lead to a stoma site incisional hernia. Recently, prophylactic mesh reinforcement of the stoma site has gained increased attention, supporting the need for accurate data on the incidence of and risk factors for stoma site incisional hernia and to identify high-risk patients. The aim of this study was to assess incidence, risk factors and prevention of stoma site incisional hernias.

METHOD

Embase, MEDLINE, Web of Science, Cochrane and Google Scholar databases were searched. Studies reporting the incidence of stoma site incisional hernia after stoma reversal were included. Study quality was assessed with the Newcastle-Ottawa Scale and Cochrane risk of bias tool. Data on incidence, risk factors and prophylactic mesh reinforcement were extracted.

RESULTS

Of 1440 articles found, 33 studies comprising 4679 reversals were included. The overall incidence of incisional hernia was 6.5% [range 0%-38%, median follow-up 27.5 (17.54-36) months]. Eleven studies assessed stoma site incisional hernia as the primary end-point, showing an incidence of 17.7% [range 1.7%-36.1%, median follow-up 28 (15.25-51.70) months]. Body mass index, diabetes and surgery for malignant disease were found to be independent risk factors, as derived from eight studies. Two retrospective comparative cohort studies showed significantly lower rates of stoma site incisional hernia with prophylactic mesh reinforcement compared with nonmesh controls [6.4% vs 36.1% (P = 0.001); 3% vs 19% (P = 0.04)].

CONCLUSION

Stoma site incisional hernia should not be underestimated as a long-term problem. Body mass index, diabetes and malignancy seem to be potential risk factors. Currently, limited data are available on the outcomes of prophylactic mesh reinforcement to prevent stoma site incisional hernia.

Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias

BACKGROUND

Reversal of an enterostomy results in a high rate of incisional hernia at the ostomy site. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. We present the outcomes of a series of prophylactic mesh reinforcements with retromuscular, large-pore polypropylene at the time of enterostomy reversal.

METHODS

Retrospective review of all ostomy reversals was performed. All cases with placement of synthetic mesh reinforcement were identified from a prospectively maintained, hernia database. Primary end points were surgical site occurrence, surgical site infection, and hernia occurrence.

RESULTS

Ostomy reversal was performed in 359 patients; 91 were reinforced with mesh and 268 without mesh. Colostomy reversal was performed in 56.5% and ileostomy in 43.5%. The mesh group had a greater body mass index and a greater incidence of chronic obstructive pulmonary disease, but groups were otherwise similar. A midline incisional hernia was present in 45% of the mesh group vs 4.5% in the controls. Incidence of surgical site occurrence and surgical site infection were similar for mesh and control groups (21 vs 22.8%; P = .82 and 20 vs 19.8%; P = 1.000, respectively). Superficial surgical site infection was less with mesh (8 vs 16.4%; P = .039). Incidence of a hernia developing at the stoma site was decreased markedly with mesh (1% vs 17.2%; P < .001), as was the occurrence of a midline hernia (6% vs 19%; P = .004). Mesh was placed across the midline prophylactically in 29.7% of cases, which decreased midline hernia formation from 24.1% to 4% (P = .019).

CONCLUSION

Retromuscular placement of permanent synthetic mesh at the time of enterostomy reversal is effective in preventing development of incisional hernia without increased risk of surgical site occurrence or surgical site infection.

Abdominal wall closure after a stomal reversal procedure

The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.