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Anwar IJ, Greenberg JA. Successful Prevention of Parastomal Hernia Formation With Intra-Abdominal Funnel-Shaped Mesh. JAMA Surg 2024; 159:1250-1251. [PMID: 39196550 DOI: 10.1001/jamasurg.2024.3252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Affiliation(s)
- Imran J Anwar
- Division of Minimally Invasive Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Jacob A Greenberg
- Division of Minimally Invasive Surgery, Department of Surgery, Duke University, Durham, North Carolina
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Fabregó B, Miralpeix E, Sole-Sedeno JM, Pereira JA, Mancebo G. Prophylactic mesh to prevent incisional hernia in laparotomy for ovarian tumors. Int J Gynecol Cancer 2024; 34:1596-1602. [PMID: 38909993 DOI: 10.1136/ijgc-2024-005427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 06/03/2024] [Indexed: 06/25/2024] Open
Abstract
OBJECTIVE Incisional hernias are a common complication of midline laparotomies. The aim of this study was to determine the impact of prophylactic mesh placement after midline laparotomy for ovarian tumors on the incidence of incisional hernia. METHODS We collected retrospective data from patients undergoing midline laparotomy for borderline or ovarian cancer with at least 12 months of follow-up, including those with and without mesh. Patient demographics, preoperative characteristics and risk factors for hernia were reported and grouped according to prophylactic mesh placement. A multivariate analysis was conducted to identify independent risk factors for incisional hernia. Kaplan-Meier curves illustrating the cumulative incidence of incisional hernia based on mesh placement were performed. RESULTS A total of 139 consecutive patients with available data were included, 58 in the non-mesh group and 81 in the mesh group, with high body mass index (BMI) as the most common reason for mesh placement. The mean (SD)) age was 60 years (13.97). A total of 11 patients (7.9%) had borderline tumors while 128 (92.1%) had invasive cancer. After clinical and radiological examination, 18.7% (26/139) of patients developed incisional hernia at a median follow-up of 35.8 months (IQR) 43.8): 31% (18/58) were detected in the non-mesh group, and 9.9% (8/81) in the mesh group (p<0.002). Multivariate analysis showed no-mesh placement (OR) 10; 95% CI) 2.8 to 35.919; p<0.001) as a significant risk factor for incisional hernia. Age ≥ 70 (OR 4.3; 95% CI 1.24 to 15; p=0.02) and BMI ≥ 29 (OR 4.4; 95% CI 1.27 to 14.93; p=0.019) were also identified as independent risk factors for hernia development. According to Kaplan-Meier curves, the cumulative incidence of incisional hernia was higher in the non-mesh group (p=0.002). CONCLUSION The incidence of incisional hernia was high in patients undergoing midline laparotomy for ovarian tumors. The addition of a prophylactic mesh may reduce this incidence, therefore there is a need to consider it as an option for high-risk patients, particularly those aged over 70 years or with a BMI ≥ 29 kg/m2.
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Affiliation(s)
- Berta Fabregó
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Josep-Maria Sole-Sedeno
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
| | - José-Antonio Pereira
- Department of Surgery, Hospital del Mar, Barcelona, Spain
- Pompeu Fabra University, Barcelona, Spain
| | - Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, Hospital del Mar, Barcelona, Catalunya, Spain
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Kanabolo DL, Park S. Prophylactic Mesh Placement With Ileal Conduit: A Cost-effectiveness Analysis. Urology 2023; 177:197-203. [PMID: 37119979 DOI: 10.1016/j.urology.2023.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/18/2023] [Accepted: 03/13/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness of mesh placement in patients undergoing ileal conduit urinary diversion for bladder cancer. Long-term studies have shown that parastomal hernias (PSH) occur in more than half of all stomas. Mesh prophylaxis has been shown to reduce PSH after end-colostomy and ileal conduits. However, no cost-effectiveness studies on mesh prophylaxis have been performed for this population. METHODS We created a Markov model incorporating the costs and effectiveness of mesh prophylaxis for patients undergoing radical cystectomy and ileal conduit construction. Costs were obtained from the literature and adjusted to 2022 US dollars. Effectiveness was measured in quality-adjusted life years (QALY). 1- and 2-way sensitivity analyses were performed to test the robustness of our model. RESULTS In stage I-IV bladder cancer, prophylactic mesh placement was costlier, but more effective in providing quality of life compared with no mesh placement at index surgery. Average incremental cost between the 2 strategies across all stages was an additional $897 when mesh was utilized. Incremental effectiveness averaged 0.49 additional QALY across all stages. This resulted in an incremental cost-effectiveness ratio of $2114.71/QALY. Sensitivity analyses indicated that benefit of mesh placement was sensitive to the probability of mesh infection. CONCLUSION In patients undergoing ileal conduit urinary diversion for bladder cancer, mesh prophylaxis at the time of radical cystectomy is an overall cost-effective strategy in preventing PSH for patients presenting with all stages of bladder cancer.
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Affiliation(s)
- Diboro L Kanabolo
- Department of Urology, University of Washington Medical Center, Seattle, WA.
| | - Sangtae Park
- Department of General Surgery, Section of Urology, NorthShore University Health System, Evanston, IL
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Ulutas ME, Sahin A, Simsek G, Sekmenli N, Kilinc A, Arslan K, Eryilmaz MA, Kartal A. Does onlay mesh placement in emergency laparotomy prevent incisional hernia? A prospective randomized double-blind study. Hernia 2023:10.1007/s10029-023-02770-7. [PMID: 36967415 DOI: 10.1007/s10029-023-02770-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/09/2023] [Indexed: 03/28/2023]
Abstract
PURPOSE The objective of this study is to assess the effectiveness and safety of onlay mesh closure of emergency midline laparotomy to prevent incisional hernia. METHODS This is a prospective randomized double-blind study and was carried out in the General Surgery Clinic, Konya City Hospital, from August 1, 2020 to August, 1, 2021. The study included 108 patients who were randomly grouped in 2 groups: patients with conventional abdominal closure and closure using additional onlay mesh (1:1). The follow-up period was for a year. The primary outcome was the incidence of incisional hernia and secondary outcomes were clinical data like complications, hospital length of stay, re-operations. RESULTS It was observed that incisional hernia was present in 14 patients (27.4%) in conventional abdominal closure group and was in 2 patients using mesh (4%), (p = 0.001). Clavien-Dindo 3B complications were in rise in conventional closure group (p = 0.02). Of all complications, burst abdomen was significantly more common in conventional closure group (p = 0.04). The rate of surgically treated complications were higher in conventional closure group (p = 0.02). Clavien-Dindo 3A complications were more common in patients with contaminated wound in mesh group (p = 0.02). CONCLUSION The use of mesh while closing the abdomen in emergency midline laparotomy reduces the risk of incisional hernia. Thus, to lower the risks of incisional hernia and its complications, prophylactic mesh can be used in high-risk patients.
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Methods of Colostomy Construction: No Effect on Parastomal Hernia Rate: Results from Stoma-const-A Randomized Controlled Trial. Ann Surg 2021; 273:640-647. [PMID: 32209907 DOI: 10.1097/sla.0000000000003843] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The primary objective of this trial was to compare the parastomal hernia rates 1 year after the construction of an end colostomy by 3 surgical techniques: cruciate incision, circular incision in the fascia and using prophylactic mesh. Secondary objectives were evaluation of postoperative complications, readmissions/reoperations, and risk factors for parastomal hernia. SUMMARY OF BACKGROUND DATA Colostomy construction techniques have been explored with the aim to improve function and reduce stoma complications, but parastomal herniation is frequent with an incidence of approximately 50%. METHODS A randomized, multicenter trial was performed in 3 hospitals in Sweden and Denmark; all patients scheduled to receive an end colostomy were asked to participate. Parastomal hernia within 12 months was determined by computed tomography of the abdomen in prone position and by clinical assessment. Complications, readmissions, reoperations, and risk factors were also assessed. RESULTS Two hundred nine patients were randomized to 1 of the 3 arms of the study. Patient demographics were similar in all 3 groups. Assessment of parastomal hernia was possible in 185 patients. The risk ratio (95% confidence interval) for parastomal hernia was 1.25 (0.83; 1.88), and 1.22 (0.81; 1.84) between cruciate versus circular and cruciate versus mesh groups, respectively. There were no statistically significant differences between the groups with regard to parastomal hernia rate. Age and body mass index were found to be associated with development of a parastomal hernia. CONCLUSION We found no significant differences in the rates of parastomal hernia within 12 months of index surgery between the 3 surgical techniques of colostomy construction.
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Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques. Hernia 2020; 25:631-638. [PMID: 32279169 DOI: 10.1007/s10029-020-02176-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/11/2020] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH. METHODS This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24). RESULTS PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195). CONCLUSION Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.
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Affiliation(s)
- Benjamin K Poulose
- Center for Abdominal Core Health, Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Gina L Adrales
- The Johns Hopkins Hospitals, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey E Janis
- Center for Abdominal Core Health, Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus
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Italian guidelines for the surgical management of enteral stomas in adults. Tech Coloproctol 2019; 23:1037-1056. [DOI: 10.1007/s10151-019-02099-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
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Abstract
After formation of a permanent terminal stoma by enterostomy, parastomal hernia (PSH) occurs in up to 80% of cases and leads to a wide variety of symptoms and complications with a high rate of emergency operations due to incarceration (ca. 15%). Consequently, greater consideration should be given to PSH prevention even as early as the time of enterostomy and generously applied indications for elective repair of manifest PSH. The aim of this article is to summarize and evaluate the current evidence for PSH repair and prevention. Poor postoperative results after attempted repair of manifest PSH with slit meshes in different layers of the abdominal wall shift the focus onto stoma lateralization (sandwich and Sugarbaker techniques) or 3‑dimensional tunnel-shaped implants with meshes to cover the stomal edges. To date, the best strategy for PSH prevention has still not been defined and techniques with slit meshes show different results. Nevertheless, 10 prospective randomized trials, meta-analyses, a Cochrane review and guidelines from the European Hernia Society (EHS) about various slit-mesh devices in sublay, onlay and intraperitoneal positions confirmed significantly reduced rates of PSH after mesh augmentation compared to conventionally sutured enterostomy without morbidity associated with the implanted material. Despite the positive data situation PSH prevention is seldom performed in daily practice, which is due to uncertainty surrounding the most suitable surgical strategy, the necessity to spend additional time at the end of a demanding operation, the aversion to implanting meshes into a contaminated operative field and the lack of remuneration of preventive surgical procedures. Future trials should, therefore, no longer compare standard enterostomy techniques with one prevention method in general but should have a new focus on techniques providing adequate results in PSH repair (Sugarbaker, sandwich and 3‑D tunnel meshes), probe the advantages and evaluate the differences in outcome between these strategies.
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Hernández-Granados P, López-Cano M, Morales-Conde S, Muysoms F, García-Alamino J, Pereira-Rodríguez JA. Incisional hernia prevention and use of mesh. A narrative review. Cir Esp 2018; 96:76-87. [PMID: 29454636 DOI: 10.1016/j.ciresp.2018.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/21/2017] [Accepted: 01/08/2018] [Indexed: 12/11/2022]
Abstract
Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.
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Affiliation(s)
- Pilar Hernández-Granados
- Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Sección de Pared Abdominal de la Asociación Española de Cirujanos, España.
| | - Manuel López-Cano
- Sección de Pared Abdominal de la Asociación Española de Cirujanos, España; Unidad de Pared Abdominal, Hospital Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Salvador Morales-Conde
- Unidad de Innovación en Cirugía Mínimamente Invasiva, Hospital Universitario Virgen del Rocío, Sevilla, España; Secretaría General, European Hernia Society
| | - Filip Muysoms
- Servicio de Cirugía, Hospital Maria Middelares, Ghent, Bélgica
| | - Josep García-Alamino
- Department of Primary Care Health Sciencies, University of Oxford, Oxford, Reino Unido
| | - José Antonio Pereira-Rodríguez
- Servicio de Cirugía General y Digestiva, Parc de Salut Mar, Hospital del Mar. Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España
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Knaapen L, Buyne O, van Goor H, Slater NJ. Synthetic vs biologic mesh for the repair and prevention of parastomal hernia. World J Meta-Anal 2017; 5:150-166. [DOI: 10.13105/wjma.v5.i6.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/29/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To outline current evidence regarding prevention and treatment of parastomal hernia and to compare use of synthetic and biologic mesh.
METHODS Relevant databases were searched for studies reporting hernia recurrence, wound and mesh infection, other complications, surgical techniques and mortality. Weighted pooled proportions (95%CI) were calculated using StatsDirect. Heterogeneity concerning outcome measures was determined using Cochran’s Q test and was quantified using I2. Random and fixed effects models were used. Meta-analysis was performed with Review Manager software with the statistical significance set at P ≤ 0.05.
RESULTS Forty-four studies were included: 5 reporting biologic mesh repairs; 21, synthetic mesh repairs; and 18, prophylactic mesh repairs. Most of the studies were retrospective cohorts of low to moderate quality. The hernia recurrence rate was higher after undergoing biologic compared to synthetic mesh repair (24.0% vs 15.1%, P = 0.01). No significant difference was found concerning wound and mesh infection (5.6% vs 2.8%; 0% vs 3.1%). Open and laparoscopic techniques were comparable regarding recurrences and infections. Prophylactic mesh placement reduced the occurrence of a parastomal hernia (OR = 0.20, P < 0.0006) without increasing wound infection [7.8% vs 8.2% (OR = 1.04, P = 0.91)] and without differences between the mesh types.
CONCLUSION There is no superiority of biologic over synthetic mesh for parastomal hernia repair. Prophylactic mesh placement during the initial surgery significantly reduces parastomal hernia occurrence regardless of the mesh type.
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Affiliation(s)
- Loes Knaapen
- Department of Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Otmar Buyne
- Department of Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Nicholas J Slater
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
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Lykke A, Andersen JFB, Jorgensen LN, Mynster T. Prevention of parastomal hernia in the emergency setting. Langenbecks Arch Surg 2017; 402:949-955. [PMID: 28612116 DOI: 10.1007/s00423-017-1596-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/29/2017] [Indexed: 01/08/2023]
Abstract
AIM This study assessed safety and efficacy associated with hernia prophylaxis using a retromuscular slowly resorbable synthetic mesh for stoma reinforcement. METHOD This was a cohort study with a historic reference group. The study took place in a high-volume surgical department. During a 2-year period (July 2012-July 2014), we included 109 patients undergoing emergency surgery with formation of ileostomy or colostomy. All patients received a retromuscular slowly resorbable synthetic mesh (TIGR®, Novus Scientific) at the stoma site. The reference group included 117 patients who underwent emergency stoma formation without a prophylactic mesh in the 2-year period prior to July 2012. The primary endpoint was effect on prevention of parastomal hernia within 1 year. Secondary endpoints were 30-day and 1-year complications including mortality. RESULTS The operative field was contaminated or dirty in 48% of the procedures. Operative time was significantly longer in the mesh group. The cumulative incidences of parastomal hernia at 1 year for the control and the mesh group were 8 and 7% (p = 0.424), respectively. The postoperative 30-day and 1-year rate of complications, reoperations and mortality were not different between the two groups. No patients underwent removal of the mesh and no clinical mesh infections were seen. CONCLUSION Use of a resorbable synthetic mesh during emergency ostomy formation showed no significant preventive effect on formation of parastomal hernia after 1 year. Although surgery was often conducted in a severely contaminated field, the procedure was without significantly increased complication rate.
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Affiliation(s)
- Anna Lykke
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Johnny F B Andersen
- Department of Radiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lars N Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Tommie Mynster
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark.
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Prophylactic Mesh Placement During Formation of an End-colostomy Reduces the Rate of Parastomal Hernia: Short-term Results of the Dutch PREVENT-trial. Ann Surg 2017; 265:663-669. [PMID: 27471840 DOI: 10.1097/sla.0000000000001903] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the incidence of parastomal hernias (PSHs) after end-colostomy formation using a polypropylene mesh in a randomized controlled trial versus conventional colostomy formation. BACKGROUND A PSH is the most frequent complication after stoma formation. Symptoms may range from mild abdominal pain to life-threatening obstruction and strangulation. The treatment of a PSH is notoriously difficult and recurrences up to 20% have been reported despite the use of mesh. This has moved surgical focus toward prevention. METHODS Augmentation of the abdominal wall with a retro-muscular lightweight polypropylene mesh was compared with the traditional formation of a colostomy. In total, 150 patients (1:1 ratio) were included. The incidence of a PSH, morbidity, mortality, quality of life, and cost-effectiveness was measured after 1 year of follow-up. RESULTS There was no difference between groups regarding demographics and predisposing factors for PSH. Three out of 67 patients (4.5%) in the mesh group and 16 out of 66 patients (24.2%) in the nonmesh group developed a PSH (P = 0.0011). No statistically significant difference was found in infections, concomitant hernias, SF-36 questionnaire, Von Korff pain score, and cost-effectiveness between both study groups. CONCLUSION Prophylactic augmentation of the abdominal wall with a retromuscular lightweight polypropylene mesh at the ostomy site significantly reduces the incidence of PSH without a significant difference in morbidity, mortality, quality of life, or cost-effectiveness.
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Mortensen AR, Grossmann I, Rosenkilde M, Wara P, Laurberg S, Christensen P. Double-blind randomized controlled trial of collagen mesh for the prevention of abdominal incisional hernia in patients having a vertical rectus abdominis myocutaneus flap during surgery for advanced pelvic malignancy. Colorectal Dis 2017; 19:491-500. [PMID: 27805791 DOI: 10.1111/codi.13552] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/18/2016] [Indexed: 02/08/2023]
Abstract
AIM The study investigated the effect of collagen mesh-assisted closure at the donor site in preventing the formation of incisional hernia following construction of a vertical rectus abdominis myocutaneus (VRAM) flap as part of pelvic surgery for recurrent colorectal cancer. METHOD The study was a double-blinded randomized controlled superiority trial that was designed and performed according to the Consolidated Standards of Reporting Trials (CONSORT) Statement. Eligible patients undergoing surgery that included a VRAM flap for advanced colorectal pelvic malignancy were prospectively randomized to conventional abdominal wound closure or collagen mesh-assisted closure. The primary end-point was incisional herniation at 1 year confirmed by CT. Secondary end-points were CT-verified incisional herniation at 3 and 36 months, clinically recognizable incisional herniation, donor-site and reconstructive-site complications, surgical mortality, postoperative morbidity, postoperative recovery and survival. RESULTS In total, 58 (29 conventional closure; 29 mesh-assisted closure) patients were included. At 1 year, incisional herniation on the CT scan was found in 12 (50%) of 24 patients in the conventional closure group, and in 8 (33%) of 24 in the mesh-assisted closure group (P = 0.38). No significant difference between the groups was found in surgical mortality, early or late complications or survival. Donor-site morbidity was comparable between the two groups. CONCLUSION No preventative effect of collagen mesh-assisted closure was observed following VRAM flap reconstruction.
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Affiliation(s)
- A R Mortensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - I Grossmann
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - M Rosenkilde
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - P Wara
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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Cross AJ, Buchwald PL, Frizelle FA, Eglinton TW. Meta-analysis of prophylactic mesh to prevent parastomal hernia. Br J Surg 2016; 104:179-186. [PMID: 28004850 DOI: 10.1002/bjs.10402] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 06/23/2016] [Accepted: 09/08/2016] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- A J Cross
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - P L Buchwald
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - F A Frizelle
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Departments of Surgery, University of Otago, Christchurch, New Zealand
| | - T W Eglinton
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Departments of Surgery, University of Otago, Christchurch, New Zealand
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Chamieh J, Tan WH, Ramirez R, Nohra E, Apakama C, Symons W. Synthetic versus Biologic Mesh in Single-Stage Repair of Complex Abdominal Wall Defects in a Contaminated Field. Surg Infect (Larchmt) 2016; 18:112-118. [PMID: 27754767 DOI: 10.1089/sur.2016.106] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Synthetic meshes have been used with varying rates of success in a contaminated setting, although their use is not widely accepted because of concerns for infection. A biologic mesh (BM) is assumed to be more resistant to infection than a synthetic mesh; however, sparse clinical data support this theory. The hypothesis for this study: Uncoated polypropylene synthetic mesh (USM) can be used to obtain a durable repair in the setting of a contaminated abdominal wall reconstruction (AWR) in a single-stage procedure with comparable infectious outcomes to a biologic mesh repair. PATIENTS AND METHODS We performed a retrospective chart review on contaminated AWR, comparing 34 BM with 24 USM with infection as the primary outcome of interest. Secondary outcomes were re-admission and re-operation. We also investigated the microbial isolates that were cultured. RESULTS Mesh groups were similar in their demographics, duration of surgery, previous mesh, surgical site class, and source of contamination. Length of stay was 4 d longer in BM, p = 0.01. Overall infection rate was 50% for BM vs. 29.2% for USM, p = 0.18. Treatment in case of infection was similar across both groups. Gram positive bacteria comprised 39% of BM microbiology vs. 63% for USM. Re-admission rate was 52.9% for BM versus 45.8% for USM, p > 0.5. The BMs re-admitted for surgical site infection/abdominal abscess were 38.9% versus 55.6% for USM. No USM were re-admitted for seroma versus 33.3% of BM, p = 0.06. Re-operation rate was 26.5% for BM versus 33.3% for USM, p > 0.5. Procedures performed at re-operation were similar between groups. Regression analysis did not demonstrate an association between mesh type and our outcomes. CONCLUSION Our results show that synthetic meshes are not inferior to biologic meshes in contaminated AWR. This is important in view of the tremendous cost disparity between these two products and the questionable ability of biologic mesh to offer a durable hernia repair.
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Affiliation(s)
- Jad Chamieh
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Wen Hui Tan
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Ricardo Ramirez
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Eden Nohra
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - Chukwuma Apakama
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
| | - William Symons
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis School of Medicine , St. Louis, Missouri
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Donahue TF, Bochner BH. Parastomal hernias after radical cystectomy and ileal conduit diversion. Investig Clin Urol 2016; 57:240-8. [PMID: 27437533 PMCID: PMC4949695 DOI: 10.4111/icu.2016.57.4.240] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/13/2016] [Indexed: 12/11/2022] Open
Abstract
Parastomal hernia, defined as an "incisional hernia related to an abdominal wall stoma", is a frequent complication after conduit urinary diversion that can negatively impact quality of life and present a clinically significant problem for many patients. Parastomal hernia (PH) rates may be as high as 65% and while many patients are asymptomatic, in some series up to 30% of patients require surgical intervention due to pain, leakage, ostomy appliance problems, urinary obstruction, and rarely bowel obstruction or strangulation. Local tissue repair, stoma relocation, and mesh repairs have been performed to correct PH, however, long-term results have been disappointing with recurrence rates of 30%–76% reported after these techniques. Due to high recurrence rates and the potential morbidity of PH repair, efforts have been made to prevent PH development at the time of the initial surgery. Randomized trials of circumstomal prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have shown significant reductions in PH rates with acceptably low complication profiles. We have placed prophylactic mesh at the time of ileal conduit creation in patients at high risk for PH development and found it to be safe and effective in reducing the PH rates over the short-term. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors associated with its development, and the use of prophylactic mesh placement for patients undergoing ileal conduit urinary diversion with the intent of reducing PH rates.
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Affiliation(s)
- Timothy F Donahue
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard H Bochner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Donahue TF, Cha EK, Bochner BH. Rationale and Early Experience with Prophylactic Placement of Mesh to Prevent Parastomal Hernia Formation after Ileal Conduit Urinary Diversion and Cystectomy for Bladder Cancer. Curr Urol Rep 2016; 17:9. [PMID: 26757903 DOI: 10.1007/s11934-015-0565-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Parastomal hernias (PH) represent a clinically significant problem for many patients after radical cystectomy and ileal conduit diversion. The prevalence may be as high as 60% and in some series, up to 30% of patients require surgical intervention due to the complications of pain, poor fit of an ostomy appliance, leakage, urinary obstruction, and bowel obstruction or strangulation. Due to the potential morbidity associated with PH repair, there have been efforts to prevent PH development at the time of the index surgery. Four randomized trials of prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have demonstrated significant reductions in PH rates with acceptably low complication rates. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors behind its development, and the rationale behind prophylactic mesh placement for patients undergoing ileal conduit urinary diversion. Additionally, we report our experience with prophylactic mesh placed at radical cystectomy at our institution.
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Affiliation(s)
- Timothy F Donahue
- John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, 20889, USA.
| | - Eugene K Cha
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
| | - Bernard H Bochner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
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19
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Marinez AC, González E, Holm K, Bock D, Prytz M, Haglind E, Angenete E. Stoma-related symptoms in patients operated for rectal cancer with abdominoperineal excision. Int J Colorectal Dis 2016; 31:635-41. [PMID: 26728024 DOI: 10.1007/s00384-015-2491-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The primary aim of this study was to characterize the frequency, severity, and distress of symptoms from the colostomy and colostomy acceptance in rectal cancer patients. The secondary aims were to study the symptomatic parastomal herniation, its relationship to stoma-related symptoms, and potential risk factors for the development of symptomatic parastomal herniation. METHODS Data was collected from the Swedish Colorectal Cancer Registry and from surgical charts. Patients operated for rectal cancer with an abdominoperineal excision in Sweden between 2007 and 2009 and alive 3 years postoperatively were contacted (n = 852). Patients who consented to participate, had a colostomy constructed during the abdominoperineal excision, and who answered a questionnaire 3 years postoperative were included (n = 495). Answers were analyzed with emphasis on stoma-related symptoms and their intensity as well as the level of distress associated with the symptoms. RESULTS Almost 90% of patients did not feel limited in their daily life by their colostomy. Patients with symptomatic parastomal hernia had a 53% higher risk of flatulence. Fifty-six patients developed symptomatic parastomal hernia (11%). The only risk factor associated with the development of symptomatic parastomal hernia was high body mass index (BMI). CONCLUSIONS This study shows that most patients do not feel limited by their stoma 3 years after surgery for rectal cancer. Symptomatic parastomal hernia was associated with high BMI but not with the surgical technique.
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Affiliation(s)
- Adiela Correa Marinez
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden.
| | - Elisabeth González
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Kajsa Holm
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - David Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden.,Department of Surgery, NU-hospital Group, Trollhättan, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
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20
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Köhler G, Emmanuel K, Schrittwieser R. Single-port parastomal hernia repair by using 3-D textile implants. JSLS 2016; 18:JSLS-D-14-00034. [PMID: 25392655 PMCID: PMC4208891 DOI: 10.4293/jsls.2014.00034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall. Methods: We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications. Results: From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively. Conclusion: We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.
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Affiliation(s)
- Gernot Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Linz, Austria
| | - Klaus Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Linz, Austria
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21
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Lambrecht JR, Larsen SG, Reiertsen O, Vaktskjold A, Julsrud L, Flatmark K. Prophylactic mesh at end-colostomy construction reduces parastomal hernia rate: a randomized trial. Colorectal Dis 2015; 17:O191-7. [PMID: 26179984 DOI: 10.1111/codi.13065] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/21/2015] [Indexed: 12/13/2022]
Abstract
AIM Parastomal hernia (PSH) is the most common complication of an end-colostomy and about one-quarter of patients need operative repair, which is often unsuccessful. A randomized trial was carried out to compare the results of using mesh or no mesh at the time of formation of a colostomy with the clinical identification of PSH as the primary outcome. METHOD In this two-centre randomized trial (Oslo University Hospital and Sykehuset Innlandet Hospital Trust, Norway), patients with rectal cancer undergoing open pelvic surgery were randomized to receive a retromuscular synthetic mesh (study group, n = 32) or no mesh (control group, n = 26) at the time of end-colostomy formation. Postoperative follow up was not blinded and included clinical examination and routine CT. RESULTS The median period of follow up was 40 (range: 84) months. There were no differences in demographic variables or complications between the study and control groups. PSH developed in two patients of the study group and in 12 of the control group [OR = 0.04 (95% CI: 0.01-0.30) and hazard ratio 0.134 (95% CI: 0.030-0.603); P < 0.001]. The number needed to treat to avoid one PSH was 2.5 patients. CT demonstrated an increase over time in the size of the fascial orifice in patients with PSH without mesh prophylaxis, in contrast to a stable size in patients with mesh and in the control patients who did not develop PSH. CONCLUSION The retromuscular insertion of synthetic mesh at the time of formation of an end-colostomy reduced the risk of PSH.
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Affiliation(s)
- J R Lambrecht
- Department of Gastroenterological Surgery, Sykehuset Innlandet Hospital Trust, Gjøvik, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - S G Larsen
- Department of Gastroenterological Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - O Reiertsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Oslo, Norway
| | - A Vaktskjold
- Department of Gastroenterological Surgery, Sykehuset Innlandet Hospital Trust, Gjøvik, Norway.,Hedmark University College, Elverum, Norway
| | - L Julsrud
- Department of Radiology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - K Flatmark
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterological Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
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22
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Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy. Dis Colon Rectum 2015; 58:943-9. [PMID: 26347966 DOI: 10.1097/dcr.0000000000000443] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce. OBJECTIVE The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection. DESIGN This is a prospective, multicenter, randomized controlled clinical trial. SETTINGS This study was conducted at 2 university and 3 central Finnish hospitals. PATIENTS From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined. INTERVENTIONS In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma. MAIN OUTCOME MEASURES The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures. RESULTS Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups. LIMITATIONS The study was limited by its small size and short follow-up time. CONCLUSIONS Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.
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23
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Valdés-Hernández J, Díaz Milanés JA, Capitán Morales LC, del Río la Fuente FJ, Torres Arcos C, Cañete Gómez J, Oliva Mompeán F, Padillo Ruiz J. Profilaxis de la hernia paraestomal mediante malla de polipropileno en espacio preperitoneal. Cir Esp 2015; 93:455-9. [DOI: 10.1016/j.ciresp.2014.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/14/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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Randomized Controlled Trial of the Use of a Large-pore Polypropylene Mesh to Prevent Incisional Hernia in Colorectal Surgery. Ann Surg 2015; 261:876-81. [DOI: 10.1097/sla.0000000000001116] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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25
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Köhler G, Hofmann A, Lechner M, Mayer F, Wundsam H, Emmanuel K, Fortelny RH. Prevention of parastomal hernias with 3D funnel meshes in intraperitoneal onlay position by placement during initial stoma formation. Hernia 2015; 20:151-9. [PMID: 25899106 DOI: 10.1007/s10029-015-1380-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 04/11/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development. METHODS We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic implantation of a three-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position. RESULTS PSH developed in three patients (3.75%). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75%) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3-47) months. CONCLUSION The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.
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Affiliation(s)
- G Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria. .,Academic Teaching Hospital of the University of Graz, Graz, Austria. .,Academic Teaching Hospital of the University of Innsbruck, Innsbruck, Austria. .,Department of Surgery, Paracelsus Medical University, Salzburg, Austria.
| | - A Hofmann
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria
| | - M Lechner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - H Wundsam
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria.,Academic Teaching Hospital of the University of Graz, Graz, Austria.,Academic Teaching Hospital of the University of Innsbruck, Innsbruck, Austria
| | - K Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria.,Academic Teaching Hospital of the University of Graz, Graz, Austria.,Academic Teaching Hospital of the University of Innsbruck, Innsbruck, Austria
| | - R H Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria.,Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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Styrke J, Johansson M, Granåsen G, Israelsson L. Parastomal hernia after ileal conduit with a prophylactic mesh: a 10 year consecutive case series. Scand J Urol 2015; 49:308-12. [DOI: 10.3109/21681805.2015.1005664] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Aquina CT, Iannuzzi JC, Probst CP, Kelly KN, Noyes K, Fleming FJ, Monson JRT. Parastomal hernia: a growing problem with new solutions. Dig Surg 2014; 31:366-76. [PMID: 25531238 DOI: 10.1159/000369279] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/19/2014] [Indexed: 12/10/2022]
Abstract
Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias.
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Affiliation(s)
- Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise (S.H.O.R.E.), Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, N.Y., USA
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28
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Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis. Surgery 2014; 156:1238-44. [DOI: 10.1016/j.surg.2014.04.035] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/16/2014] [Indexed: 12/18/2022]
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Köhler G, Koch OO, Antoniou SA, Lechner M, Mayer F, Klinge U, Emmanuel K. Parastomal hernia repair with a 3-D mesh device and additional flat mesh repair of the abdominal wall. Hernia 2014; 18:653-61. [PMID: 25112385 DOI: 10.1007/s10029-014-1302-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 07/28/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE Parastomal hernias (PSHs) have been a major clinical problem. The aim of this study was to evaluate a new method of PSH repair in combination with an additional flat mesh reinforcement of the abdominal wall. METHODS In a pilot case series, seven patients suffering from complex PSHs (≥5 cm diameter and/or recurrence) underwent surgery and were treated by intraperitoneal onlay technique (IPOM) with a synthetic 3-D funnel-shaped mesh implant. The demographics, perioperative, and follow-up data are presented in this report. RESULTS The surgical strategy varied between purely laparoscopic (n = 1), laparoscopically assisted (hybrid n = 3), or open techniques (n = 3) using original or suture-reconstructed mesh devices. The funnel mesh implantations in IPOM technique were combined with attached flat meshes in the appropriate position of the abdominal wall. No procedure-related complications occurred. The mean length of hospital stay was 12 days and the mean operating time was 171 min. No recurrence of PSH or incisional hernias was observed during a mean follow-up period of 12.3 months (range from 7 to 22). CONCLUSION The use of a 3-D mesh implant has so far shown to be a promising option in the treatment of primary and recurrent PSHs. Its use proved to be reasonable in both laparoscopic and open IPOM technique. PSHs were preferably repaired using the original, unmodified implant, but when we also found it safe to incise, place and then suture the mesh around the pre-existing ostomy.
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Affiliation(s)
- G Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria,
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Correa Marinez A, Erestam S, Haglind E, Ekelund J, Angerås U, Rosenberg J, Helgstrand F, Angenete E. Stoma-Const--the technical aspects of stoma construction: study protocol for a randomised controlled trial. Trials 2014; 15:254. [PMID: 24970570 PMCID: PMC4094442 DOI: 10.1186/1745-6215-15-254] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The construction of a colostomy is a common procedure, but the evidence for the different parts of the construction of the colostomy is lacking. Parastomal hernia is a common complication of colostomy formation. The aim of this study is to standardise the colostomy formation and to compare three types of colostomy formation (one including a mesh) regarding the development of parastomal hernia. METHODS/DESIGN Stoma-Const is a Scandinavian randomised trial comparing three types of colostomy formation. The primary endpoint is parastomal herniation as shown by clinical examination or CT scan within one year. Secondary endpoints are re-admission rate, postoperative complications (classified according to Clavien-Dindo), stoma-related complications (registered in the case record form at stoma care nurse follow-up), total length of hospital stay during 12 months, health-related quality of life and health economic analysis as well as re-operation rate and mortality within 30 days and 12 months of primary surgery. Follow-up is scheduled at 4-6 weeks, and 6 and 12 months. Inclusion is set at 240 patients. DISCUSSION Parastomal hernia is a common complication after colostomy formation. Several studies have been performed with the aim to reduce the rate of this complication. However, none are fully conclusive and data on quality of life and health economy are lacking. The aim of this study is to develop new standardised techniques for colostomy formation and evaluate this with patient reported outcomes as well as clinical and radiological assessment. TRIAL REGISTRATION Clinicaltrials.gov, NCT01694238.2012-09-24.
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Affiliation(s)
| | | | | | | | | | | | | | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, SSORG - Scandinavian Surgical Outcomes Research Group, University of Gothenburg, Sahlgrenska University Hospital/Östra, 416 85 Gothenburg, Sweden.
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Strangulated ileostomy evisceration following lateralizing mesh repair of parastomal hernia. Hernia 2014; 20:327-30. [PMID: 24777430 DOI: 10.1007/s10029-014-1259-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 04/10/2014] [Indexed: 10/25/2022]
Abstract
Parastomal hernia formation and ostomy prolapse are relatively common complications of intestinal ostomy construction. Underlay mesh placement with lateralization of the stoma limb appears to be the method of repair with the lowest recurrence rate. Prophylaxis of new stomas with mesh is advocated by many authors. We report the case of an 81-year-old man with chronic steroid-dependent COPD who presented to the emergency department with strangulated small bowel evisceration 9 days following completion abdominal colectomy, and creation of an end ileostomy reinforced with intraperitoneal mesh. This rare complication was related to this patient's risk factors for poor healing including poor nutrition, age, chronic COPD and coughing and steroid dependence with immunosuppression.
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Results of 3-dimensional mesh implantations at the time of Miles operation to prevent parastomal hernia. Eur Surg 2014. [DOI: 10.1007/s10353-013-0245-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Donahue TF, Bochner BH, Sfakianos JP, Kent M, Bernstein M, Hilton WM, Cha EK, Yee AM, Dalbagni G, Vargas HA. Risk factors for the development of parastomal hernia after radical cystectomy. J Urol 2013; 191:1708-13. [PMID: 24384155 DOI: 10.1016/j.juro.2013.12.041] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Parastomal hernia is a frequent complication of stoma formation after radical cystectomy. We determined the prevalence and risk factors for the development of parastomal hernia after radical cystectomy. MATERIALS AND METHODS We conducted a retrospective study of 433 consecutive patients who underwent open radical cystectomy and ileal conduit between 2006 and 2010. Postoperative cross-sectional imaging studies performed for routine oncologic followup (1,736) were evaluated for parastomal hernia, defined as radiographic evidence of protrusion of abdominal contents through the abdominal wall defect created by forming the stoma. Univariable and multivariable Cox regression analyses were used to determine clinical and surgical factors associated with parastomal hernia. RESULTS Complete data were available for 386 patients with radiographic parastomal hernia occurring in 136. The risk of a parastomal hernia developing was 27% (95% CI 22, 33) and 48% (95% CI 42, 55) at 1 and 2 years, respectively. Clinical diagnosis of parastomal hernia was documented in 93 patients and 37 were symptomatic. Of 16 patients with clinical parastomal hernia referred for repair 8 had surgery. On multivariable analysis female gender (HR 2.25; 95% CI 1.58, 3.21; p<0.0001), higher body mass index (HR 1.08 per unit increase; 95% CI 1.05, 1.12; p<0.0001) and lower preoperative albumin (HR 0.43 per gm/dl; 95% CI 0.25, 0.75; p=0.003) were significantly associated with parastomal hernia. CONCLUSIONS The overall risk of radiographic evidence of parastomal hernia approached 50% at 2 years. Female gender, higher body mass index and lower preoperative albumin were most associated with the development of parastomal hernia. Identifying those at greatest risk may allow for prospective surgical maneuvers at the time of initial surgery, such as placement of prophylactic mesh in selected patients, to prevent the occurrence of parastomal hernia.
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Affiliation(s)
- Timothy F Donahue
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - John P Sfakianos
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Matthew Kent
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Melanie Bernstein
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - William M Hilton
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Eugene K Cha
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Alyssa M Yee
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Hebert A Vargas
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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Carr JA. Tissue Expander-Assisted Ventral Hernia Repair for the Skin-Grafted Damage Control Abdomen. World J Surg 2013; 38:782-7. [DOI: 10.1007/s00268-013-2377-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Surgical outcome results after repair for parastomal hernia are sparsely reported and based on small-scale studies. OBJECTIVE This study aims to analyze surgical risk factors for 30-day reoperation and mortality, and, secondarily, to report the risk of reoperation for recurrence. DESIGN This is a retrospective analysis of nationwide perioperative surgical variables. The primary outcome was reoperation for surgical complications and/or mortality within 30 days after parastomal hernia repair. Follow-up was obtained from the Danish National Patient Register. Detailed patient-related data were based on hospital files. Multivariate analysis was based on a compound parameter: 30-day reoperation or death. SETTING AND PATIENTS All patients with a parastomal hernia repair registered in the Danish Hernia Database from January 1, 2007 to December 31, 2010 were included. MAIN OUTCOME MEASURES Univariate and logistic regression was used to identify risk factors for 30-day reoperation or death. RESULTS The study included 174 patients with a parastomal hernia repair (142 elective and 32 emergency repairs; 56 open and 118 laparoscopic repairs). Median follow-up was 20 months (range, 0-47). A total of 13.2% were reoperated because of postoperative complications, and 6.3% of patients died within the first 30 postoperative days. Emergency repair was the strongest risk factor for reoperation or death in multivariate analyses (OR, 7.6; 95% CI, 2.7-21.5). No difference was found in preoperative risk of poor outcome between elective and emergency repairs (Charlson score 4 (range, 0-12) vs 5 (0-11), p = 0.07). After 3 years, the cumulated reoperation rate for recurrence was 10.8% (open 17.2% and laparoscopic 3.8%). LIMITATIONS Patients' comorbidity was based on retrospective data, and the study had a relatively short follow-up. CONCLUSION In the present nationwide study, repair for a parastomal hernia was associated with high rates of morbidity, mortality, and repair for recurrence. Emergency repair was the only important risk factor to predict poor 30-day postoperative outcome.
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Carbonell AM, Cobb WS. Safety of Prosthetic Mesh Hernia Repair in Contaminated Fields. Surg Clin North Am 2013; 93:1227-39. [DOI: 10.1016/j.suc.2013.06.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
Stomas are created for a wide range of indications such as temporary protection of a high-risk anastomosis, diversion of sepsis, or permanent relief of obstructed defecation or incontinence. Yet this seemingly benign procedure is associated with an overall complication rate of up to 70%. Therefore, surgeons caring for patients with gastrointestinal diseases must be proficient not only with stoma creation but also with managing postoperative stoma-related complications. This article reviews the common complications associated with ostomy creation and strategies for their management.
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Affiliation(s)
- Andrea C Bafford
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD 21230, USA
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Abstract
Stoma creation in the obese patient presents technical challenges beyond the usual considerations that surround stoma creation. Both short-term and long-term stoma complication rates are higher in the obese patient. One must always strive to create a protruding well-vascularized stoma while maximizing the potential to restore bowel continuity in the future. This article will discuss the potential complications and difficulties associated with the creation of a stoma in the obese patient. It will also discuss the traditional techniques for creating the stoma and include modifications that may be required in the obese patient. It will cover technical tips that may help to avoid the complications and pitfalls of creating a stoma in the obese patient.
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Affiliation(s)
- Sandra J Beck
- Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky
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Souza JM, Dumanian GA. Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair. Surgery 2012; 153:393-9. [PMID: 23068089 DOI: 10.1016/j.surg.2012.08.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 08/03/2012] [Indexed: 01/30/2023]
Abstract
BACKGROUND The Ventral Hernia Working Group (VHWG) recently proposed a grading system to assist surgeons in selecting the appropriate mesh based on an individual patient's risk of developing a postoperative complication. The VHWG grading scale was used to evaluate the incidence of surgical-site complications in 100 consecutive midline ventral hernias repaired with uncoated mid-weight polypropylene mesh. METHODS A retrospective review was conducted of 100 consecutive cases of midline ventral hernia repair using an intra-abdominal mesh underlay between July 2005 and May 2010. The median duration of follow-up was 23 months. RESULTS Using the VHWG scale, 50 percent of cases were considered grade 2 ("Co-morbid") and 28 percent considered Grade 3 ("Potentially Contaminated"). The remaining cases were Grade 1 ("Low-risk"). Overall, there was a 5.6 percent rate of hernia recurrence, with a mean time to recurrence of 17 months. There were no enterocutaneous fistulae or infections requiring mesh removal. CONCLUSION The use of uncoated mid-weight polypropylene mesh for reinforcement of midline ventral hernia repairs was not associated with increased rates of infection, fistula formation, or clinically significant adhesions. These findings challenge the recommendation by the VHWG to avoid synthetic repair material in patients with comorbidities or in "potentially contaminated" fields.
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Affiliation(s)
- Jason M Souza
- Northwestern University, Feinberg School of Medicine, Division of Plastic and Reconstructive Surgery, Chicago, IL, USA
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Rostas JW. Preventing Stoma-Related Complications: Techniques for Optimal Stoma Creation. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2011.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
INTRODUCTION The prevalence of parastomal hernia (PSH) varies considerably in the literature. This condition impacts negatively on quality of life. Yet there is no surgical consensus concerning treatment. The aim of the study was to determine treatment and recurrence rates of PSH in a large population of ostomy patients. PATIENTS AND METHODS This retrospective study was carried out by a self-administered questionnaire in a population drawn at random from the database of the French federation of ostomy patients (FSF). RESULTS Seven hundred and eighty-two patients were eligible for the study. The mean duration of follow-up was 10.5 years. PSH was reported by 202 patients (25.6%) and appeared on average 18 months after creation of the stoma. In multivariate analysis, ileostomy had a lower risk of developing PSH than did colostomy; age mote than 60 years and peristomal complications at the time of stoma creation increased the risk. Only 24% of patients with PSH were free from symptoms related to the hernia. The main complaints were pain (35%), difficulties in fitting a stomal appliance with leakage (28%); 114 patients (56%) underwent operative repair. The morbidity rate of reoperation was 33%, and 57 patients (52%) had recurrence of PSH within an average of 6 months. Transposition of the stoma to another location and the use of prosthetic mesh decreased recidivism AF recurrence? CONCLUSION PSH aggravates the inherently diminished quality of life of stoma patients. There are many proposed surgical treatments but recurrence occurs in more than half of patients. Randomized trials on the treatment of PSH are nonexistent. The use of a prosthetic mesh may reduce the risk of recurrence. The prophylactic use of prophylactic mesh at the time of initial stoma formation is a strategy worthy of consideration.
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Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR, Vick CC. Predictors of mesh explantation after incisional hernia repair. Am J Surg 2011; 202:28-33. [PMID: 21741517 DOI: 10.1016/j.amjsurg.2010.10.011] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 10/11/2010] [Accepted: 10/11/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known. METHODS This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002. RESULTS Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4-22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation. CONCLUSIONS Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.
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Affiliation(s)
- Mary T Hawn
- Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Veterans Administration Hospital, AL 35233, USA.
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Smart NJ, Velineni R, Khan D, Daniels IR. Parastomal hernia repair outcomes in relation to stoma site with diisocyanate cross-linked acellular porcine dermal collagen mesh. Hernia 2011; 15:433-7. [PMID: 21279662 DOI: 10.1007/s10029-011-0791-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 01/09/2011] [Indexed: 12/31/2022]
Abstract
PURPOSE Biologic meshes are increasingly used in parastomal hernia repair. This study evaluates the efficacy and safety of diisocyanate cross-linked acellular porcine dermal collagen mesh for parastomal hernia repair, with particular reference to the relationship of the stoma site to the rectus sheath. METHODS Hernias were repaired via a lateral approach, with onlay placement of the biologic mesh. A retrospective case note review and analysis of clinical outcomes was performed. The relationship of the stoma to the rectus sheath was determined by abdominal computed tomography (CT) and intraoperative findings. RESULTS Over a 16-month period, 27 consecutive patients, median age 72 years, underwent parastomal hernia repair utilising onlay biologic mesh to reinforce the external oblique aponeurosis. There were 20 paracolostomy and seven paraileostomy hernias. Eleven stomas passed through the rectus sheath and 16 were lateral to it. Recurrences occurred in 3 of 11 stomas within and 12 of 16 stomas lateral to the rectus sheath (P = 0.022). The median time to recurrence was 10.1 months. The median follow up of patients without recurrence was 16.6 months (range 0.2-39.3). There was one perioperative death. One patient developed a superficial post-operative abscess that was managed conservatively, but there were no complications related to the biologic mesh and no mesh required removal. CONCLUSIONS For parastomal hernias within the rectus sheath, diisocyanate cross-linked porcine dermal collagen mesh onlay repair gives good results and is safe to use. Repair of a parastomal hernia where the stoma is lateral to the rectus sheath has a significantly higher risk of recurrence and is not recommended.
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Affiliation(s)
- N J Smart
- Exeter Colorectal Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK
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