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| REVIEW ARTICLES |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 1-5 |
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What is new in parastomal hernia repair: An overview
Henry Hoffmann, Debora Nowakowski, Philipp Kirchhoff
ZweiChirurgen and Merian Iselin Clinic, Center of Hernia Surgery and Proctology, Basel, Switzerland
| Date of Submission | 05-Dec-2022 |
| Date of Decision | 19-Jan-2023 |
| Date of Acceptance | 27-Jan-2023 |
| Date of Web Publication | 30-Mar-2023 |
Correspondence Address:
Henry Hoffmann
ZweiChirurgen and Merian Iselin Clinic, Center of Hernia Surgery and Proctology, Basel
Switzerland
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_65_22
Parastomal hernias (PSH) are a frequent problem mostly developing 2–3 years after index surgery impairing the life quality of affected patients. Therefore, effective prevention and treatment seems of utmost importance. However, many different surgical techniques for the treatment of PSH have been described with partially contradicting results and a low level of evidence. Therefore, this article focuses on a systematic overview of prevention and treatment for PSH. Regarding the prevention of PSH mesh-based techniques are suggested to reduce the rate of subsequent PSH, although the “keyhole” mesh, which is often used, has been shown to be ineffective for many reasons. For the treatment of PSH, the use of “funnel-shaped” meshes or Sugarbaker repair provides the most promising results. The keyhole mesh repair of PSH should be abandoned. Keywords: Funnel mesh, keyhole, parastomal hernia, sugarbaker
How to cite this article:
Hoffmann H, Nowakowski D, Kirchhoff P. What is new in parastomal hernia repair: An overview. Int J Abdom Wall Hernia Surg 2023;6:1-5 |
| Introduction | |  |
Parastomal hernia (PSH) is a complex and frequent problem. Repair of PSH is difficult and associated with a higher rate of surgical site occurrences compared to ventral hernia repairs.[1],[2],[3],[4] However, the true incidence of PSH is not known. Some reports vary from 40% to 100% incidence.[5],[6],[7],[8],[9] The cumulative risk of PSH development appears to increase with time, but the majority of PSHs develop within 2 years of ostomy creation.[6],[10] Regarding the medical history of patients, the risk for developing PSH is increased with diverticulitis, cirrhosis, benign prostatic enlargement, previous diagnosis of hernia, a smoking history, type of ostomy, stoma size, higher age and abdominal girth, female sex, diabetes, and postoperative Clavien-Dindo Grade III and IV complications.[9],[10]
The clinical symptoms of PSH are characterized by decreased ability to care for stoma, irrigation, skin irritation, sensations of fullness in the parastomal area, mild to moderate discomfort when lifting, straining or standing for a prolonged period of time, and fatigue.[11] Highest rates of PSH are found in end-colostomies.[6],[9]
Many different mesh-based techniques have been described, such as keyhole meshes, funnel meshes, and meshes deviating the stoma, such as “Sugarbaker” or “Pauli” repair.[12],[13],[14],[15],[16],[17] Like in incisional hernia, prevention during index surgery has attracted increased attention among surgeons.[12],[15],[16] Recently, the European Hernia Society published guidelines for prevention and treatment of PSHs. However, due to the lack of high-evident and biased data[18], only prophylactic mesh during the index procedure to prevent PSH was recommended, and the need for more high-evident data, audited monitoring of outcomes, and reporting of adverse events is strongly articulated.[19],[20]
This article focusses on an overview on current treatment and prevention concepts of PSHs in end-colostomies. A review of PubMed, MEDLINE (bibliographic database of National Library of Medicine), EMBASE (biomedical literature database), and the Cochrane database was performed according to updated PRISMA guidelines.[21] Studies analyzing methods of prevention and treatment of PSHs were included and rated using the JADAD (is named after the inventor Dr. Alejandro Jadad) score[22] evaluating randomization, blinding, and rates of withdrawals and dropouts.
| Prevention of Parastomal Hernias | | |
A summary of reviewed studies is shown in [Table 1]. Like in incisional hernia, all measures of prevention of PSH have recently gained more interest among surgeons. A recent meta-analysis of randomized controlled studies (RCTs) using prophylactic mesh during initial stoma creation to prevent parastomal herniation revealed that prophylactic mesh reinforcement during initial stoma creation reduces the incidence of PSH and potentially its repair, without increasing peristomal complications.[23] However, substantial heterogeneity among included RCTs limits confidence in the results. Most available studies focus on the use of a keyhole mesh since this does not need much more additional surgical work at the time of the creation of the stoma. A recent RCT including 83 patients compared keyhole mesh versus no mesh during laparoscopic abdomino-perineal resection and creation of an end-colostomy.[24] Surprisingly, after 5-year follow-up (48 patients lost to follow-up), the “mesh” group had clinically more PSH compared to the “non-mesh” group (20% vs. 15%, P = 0.45). However, radiological assessment revealed a PSH rate of 45% in the “mesh” group and 58% in the “non-mesh” group (P = 0.72). In a subanalysis of 70 patients using register data at 1-year follow-up, PSH rate was 26% in the “mesh” group and 46% in the “non-mesh” group (P = 0.10) and the risk for undergoing subsequent PSH repair was 3% in the “mesh” group and 17% in the “non-mesh” group (P = 0.030).[24] Another multicenter RCT (GRECCAR 7 trial) randomized 200 patients for no mesh versus 10 cm× 10 cm sublay keyhole synthetic mesh during the formation of an end-colostomy with a 24-months follow-up.[15] The keyhole mesh group did not show any benefit regarding reducing the rate of PSH developing after surgery. The same group of authors concluded in a meta-analysis that prophylactic mesh should not be recommended during forming end-colostomy, since it fails to reduce the rate of PSH.[25] Not surprisingly, most included studies in this analysis used keyhole meshes as the intervention and the heterogeneity of studies was high. However, no control group was available. Another RCT comparing keyhole biosynthetic mesh in an onlay position versus no mesh during the creation of an end-colostomy in emergency surgery revealed a lower PSH rate in the mesh-group after 12 months.[26] One retrospective study revealed that a retromuscular keyhole mesh can reduce the risk for PSH in end-colostomies but increases the risk for PSH in permanent ileostomies.[27]
Only a few studies evaluating the effect of 3D meshes are available. One study analyzed the effect of a 3D funnel mesh versus no mesh during creation of end-colostomies, which showed significant lower PSH rates using the mesh at the 12-month follow-up (11% vs. 54%).[16] Another retrospective revealed that prophylactic implantation of a 3D funnel-shaped intraperitoneal mesh is a safe and effective method to prevent PSH in patients requiring permanent end colostomy, significantly reducing reoperation rates due to PSH.[28] Preventive keyhole meshes are affecting the rectus muscle function too. A recent prospective study of 116 patients undergoing Hartmann’s procedure, in which 70 patients received a retromuscular keyhole mesh, showed that placement of a prophylactic retro-muscular stoma mesh resulted in a high frequency of rectus abdominis muscle atrophy distal to the stomal aperture and patients with such atrophy—surprisingly—led to a lower risk of developing a PSH.[29]
| Treatment of Parastomal Hernias | | |
A summary of reviewed studies is shown in [Table 2]. The data regarding treatment of PSH are sparse too. A study using onlay mesh reinforcement during different types of stoma formation revealed the highest rates for PSH development in end-colostomies (40%), followed by end-ileostomies (25%) and ileal conduits (21%).[17] A recent retrospective evaluation of the Danish hernia database from 2010 to 2017 including 1016 patients with a permanent stoma and a parastomal bulge revealed that most PSH appear within a 2-year period after the index procedure.[30] The cumulative incidence of a primary repair was 9% within 1 year and 19% within 5 years after the occurrence of a parastomal bulge. The main primary repair of PSH was open or laparoscopic repair with mesh (43%) followed by stoma revision (39%). After PSH repair, the probability of having a recurrence requiring repair within 5 years was 33%.[30] Another study from Finland evaluated a national patient cohort (n = 235) from nine participating hospitals in the time period of 2007–2017.[31] The outcome was PSH recurrence after primary PSH repair. The most frequent application techniques were Sugarbaker repair (38.8%), repair with a keyhole mesh (16.3%), and sandwich techniques (15.4%). Also, specific 3D-intra-abdominal funnel-shaped mesh was used in 8.3% of cases. After a median follow-up time of 39 months, the highest rates for PSH recurrence were found in keyhole-mesh repair (36%) and Sugarbaker repair (22%). The lowest recurrence rates were found in 3D-funnel-shaped meshes (15%) and Sandwich techniques (14%).[31] These findings were supported by another comparative analysis revealing significant fewer PSH recurrence rates for Sandwich techniques compared to keyhole mesh repair.[13] In a very recent meta-analysis comparing keyhole versus Sugarbaker repair for PSH, authors found lower rates of PSH recurrence following Sugarbaker repairs.[32] Another prospective study from 2007 including 66 patients investigated a new technique using a combination of two meshes. An incised mesh was placed around the stoma sling. The second mesh was used to cover the abdominal wall with the first mesh; the stoma sling was placed between the two meshes for at least 5 cm.[33] Unfortunately, no further comparative studies were conducted with this technique.
In order to get most of the mesh out of the abdominal cavity while keeping the lateralization of the stoma a novel method of open PSH repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration has been described.[34] Another post hoc analysis from an RCT[35] compared retromuscular biological keyhole mesh versus synthetic keyhole mesh for repairing PSH.[36] The cost of using biological keyhole meshes was significantly higher, while no difference regarding wound morbidity, reoperations, 2-year hernia recurrence rates, and quality of life could be demonstrated.[36] PSH repair is associated with high complication rates. With the background of an increasing number of patients with obesity, a recent analysis revealed a significantly increased risk for complications in patients with a BMI of ≥35.0 kg/m2.[37]
| Summary | | |
The incidence of PSH is unacceptably high. Most PSH develop withing 2–3 years after index surgery. Prevention seems the most effective tool to reduce the rate of PSH especially in end-colostomy formation or in cases where later stoma take down is unlikely. However, willingness to invest further OR time—especially using more complex 3D funnel meshes or Sugarbaker-repairs—during the index procedure is low, which explains the predominance of keyhole meshes in the literature. However, available studies using a keyhole mesh must be interpreted with caution since they are often lacking a sufficient follow-up period[26] or show contradictory results.[27] Also biological keyhole mesh repair must be abandoned since this technique has been proven to as ineffective as synthetic keyhole meshes.[35],[36] The reason for the ineffectiveness of keyhole mesh may root in the chosen mesh dimensions, which rarely exceeding 10 cm × 10 cm size, and the fact that keyhole meshes carry an implemented risk for recurrence by leaving a hole in the center of the mesh. Unfortunately, more keyhole mesh studies are in the recruiting phase and will very likely fail to add useful evidence to the topic. The fear of mesh increasing the risk of peristomal complications has been proven to be unjustified.[23] Overall evidence suggests that funnel mesh or deviating mesh reinforcement (Sugarbaker, Pauli repair) are both effective for prevention and treatment of PSH.[13] Further upcoming studies will provide more data derived from RCTs.[29],[38]
Financial support and sponsorship
Nil.
Conflicts of interest
Dr. Henry Hoffmann is an Associate Editor of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editor and their research groups.
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[Table 1], [Table 2]
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