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Parastomal hernia: clinical studies on definitions and prevention
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aims of the studies was to evaluate the short and long term effects on the development of parastomal hernia and stoma complications of a prophylactic prosthetic mesh placed in a sublay position at the index operation.  Also the purpose was to validate a definition of parastomal hernia at clinical examination and a method and a definition of parastomal hernia at CT-scan.

In the first two studies 27 patients were randomized to a conventional stoma or to a stoma with the addition of a partly absorbable low weight large pore mesh in sublay position. Patients were examined after one and five years.  After five years the rate of parastomal hernia was 80% with a conventional stoma and 14% with the addition of a mesh.  A prophylactic mesh did not increase the rate of complications. In the third study a prophylactic mesh was intended at stoma formation in 93 consecutive patients in routine surgery. In 75 patients provided with a mesh the rate of parastomal hernia after one year was 13%. Complication rates were not increased in 19 severely contaminated wounds. In the fourth study 27 patients with ostomies were examined by tree surgeons and parastomal hernia was defined as any protrusion in the vicinity of the stoma. CT-scans with patients examined in the supine and prone positions were assessed by three radiologists. Herniation was then defined as any intra abdominal content protruding beyond peritoneum or the presence of a hernia sac. Kappa was 0.85 for surgeons and 0.85 for radiologists with CT-scan in the prone position. Kappa was 0.80 for surgeons and radiologists collectively, with CT-scan in the prone position. Four parastomal hernias detected at CT-scan in the prone position could not be detected in the supine position. A parastomal hernia diagnosed at clinical examination was always detected at CT-scan in the prone position.

Conclusions: A prophylactic mesh placed in a sublay position at the index operation reduces the rate of parastomal hernia without increasing the rate of complications. Parastomal hernia should at clinical examination be defined as any protrusion in the vicinity of the stoma with the patient straining in the supine and erect positions.  At CT-scan, with the patient examined in the prone position, herniation should be defined as any intra abdominal content protruding beyond peritoneum or the presence of a hernia sac.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2010. , 59 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1362
Keyword [en]
Parastomal hernia, stoma complications, prosthetic mesh, mesh complications, sigmoid stoma, ileostomy, laparoscopic stoma, CT-scan
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-36142ISBN: 978-91-7459-052-4 (print)OAI: oai:DiVA.org:umu-36142DiVA: diva2:353470
Public defence
2010-11-19, Aulan, Utbildningsavdelningen 1 tr Länssjukhuset Sundsvall-Härnösand, Länssjukhuset Sundsvall-Härnösand, Sundsvall, 13:00 (Swedish)
Opponent
Supervisors
Note
Embargo, publiceras 2011-05-01Available from: 2010-11-01 Created: 2010-09-20 Last updated: 2010-11-01Bibliographically approved
List of papers
1. Preventing parastomal hernia with a prosthetic mesh
Open this publication in new window or tab >>Preventing parastomal hernia with a prosthetic mesh
2004 (English)In: Archives of surgery (Chicago. 1960), ISSN 0004-0010, E-ISSN 1538-3644, Vol. 139, no 12, 1356-1358 p.Article in journal (Refereed) Published
Abstract [en]

HYPOTHESIS: Parastomal hernia is a common complication following colostomy. The lowest recurrence rate has been produced when repair is with a prosthetic mesh. This study evaluated the effect on stoma complications of using a mesh during the primary operation. DESIGN: Randomized clinical study. METHODS: Patients undergoing permanent colostomy were randomized to have either a conventional stoma or the addition of a mesh placed in a sublay position. The mesh used was a large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material. RESULTS: Twenty-seven patients had a conventional stoma, and in 27 patients the mesh was used. No infection, fistula formation, or pain occurred (observation time, 12-38 months). At the 12-month follow-up, parastomal hernia was present in 13 of 26 patients without a mesh and in 1 of 21 patients in whom the mesh was used. CONCLUSIONS: A lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the stoma site is not associated with complications and significantly reduces the rate of parastomal hernia.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-22715 (URN)10.1001/archsurg.139.12.1356 (DOI)15613293 (PubMedID)
Available from: 2009-05-15 Created: 2009-05-15 Last updated: 2017-12-13Bibliographically approved
2. Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study
Open this publication in new window or tab >>Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study
2009 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 33, no 1, 118-121 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Parastomal hernia is a major clinical problem. In a randomized, clinical trial, a prosthetic mesh in a sublay position at the index operation reduced the rate of parastomal hernia at 12-month follow-up, without any increase in the rate of complications. This study was designed to evaluate the rate of complications after 5 years.

METHODS: Between January 2001 and April 2003, 54 patients who had a permanent ostomy were randomized to a conventional stoma or to a stoma with the addition of a mesh in a sublay position. A large-pore, lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material was used.

RESULTS: After 5 years, 21 patients with a conventional stoma were alive and parastomal herniation was recorded in 17 patients, of whom repair had been demanded in 5. In 15 patients operated on with the addition of a mesh herniation, that did not require repair, was present in 2 (P<0.001). No fistulas or strictures developed. No mesh infection was noted and no mesh was removed during the study period.

CONCLUSIONS: At stoma formation, a prophylactic low-weight mesh in a sublay position is a safe procedure that reduces the rate of parastomal hernia.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-22666 (URN)10.1007/s00268-008-9785-4 (DOI)19011935 (PubMedID)
Available from: 2009-05-14 Created: 2009-05-14 Last updated: 2017-12-13Bibliographically approved
3. Experiences with a prophylactic mesh in 93 consecutive ostomies
Open this publication in new window or tab >>Experiences with a prophylactic mesh in 93 consecutive ostomies
2010 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 34, no 7, 1637-1640 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Parastomal hernia may be present in half of patients after one year. A prophylactic low-weight prosthetic mesh in a sublay position at the index operation reduces the risk of parastomal hernia, without increasing the rate of complications. MATERIAL: Between April 2003 and November 2006 all patients with an ostomy created at an open laparotomy were followed for at least one year. RESULTS: A prophylactic mesh was used in 75 of 93 patients. In 9 a prophylactic mesh could not be placed due to scarring after previous surgery. In 9 a mesh was omitted after surgeon's decision. In 19 patients a mesh was used in severely contaminated wounds. With a mesh 6 of 73 (8%) patients developed a surgical site infection and without a mesh 4 of 15 (27%). With a mesh parastomal hernia was present in 8 of 61 (13%) patients and without a mesh in 8 of 12 (67%). CONCLUSIONS: Creating a stoma in routine open surgery a prophylactic mesh can be placed in most patients. A mesh does not increase the rate of complications and can be used in severely contaminated wounds.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-35756 (URN)10.1007/s00268-010-0492-6 (DOI)000279103400034 ()20182719 (PubMedID)
Available from: 2010-09-02 Created: 2010-09-02 Last updated: 2017-12-12Bibliographically approved
4. Parastomal hernia: clinical and radiological definitions
Open this publication in new window or tab >>Parastomal hernia: clinical and radiological definitions
2011 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 2, 189-192 p.Article in journal (Other academic) Published
Abstract [en]

INTRODUCTION: Parastomal hernia is a frequent complication after stoma formation. No consistent definition of parastomal hernia has been used in previous studies using clinical examination or computed tomography (CT) scan. The correlation between herniation rates found with clinical examination and CT scan has been poor. A definition of parastomal hernia with clinical examination that correlates with findings from CT scan should be sought.

METHODS: Parastomal hernia, was with surgeons' clinical examination, defined as any protrusion in the vicinity of the stoma with the patient straining in a supine and an erect position. A new CT scan method was developed with the patient examined in the prone position. Radiologists defined herniation as any intra-abdominal content protruding beyond the peritoneum or the presence of a hernia sac. The correlation between investigators and methods were estimated by calculating Fleiss' Kappa values.

RESULTS: Twenty-seven patients were assessed by three surgeons and three radiologists. For the surgeons, the Kappa value was 0.85. For the radiologists, it was 0.85 with CT scan in the prone position and 0.82 in the supine position. For the surgeons and radiologists collectively, the Kappa value was 0.80 for CT scan in the prone position and 0.63 in the supine position.

CONCLUSION: With the new CT scan method examining patients in the prone position, the clinical and radiological definitions were highly reproducible and correlated strongly between methods and raters. With the strong correlation between clinical and radiological assessments, clinical examination alone is sufficient as follow-up. Conventional CT scan with the patient supine is not a reliable tool for diagnosing parastomal hernia.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-36752 (URN)10.1007/s10029-010-0769-6 (DOI)21188441 (PubMedID)
Available from: 2010-10-11 Created: 2010-10-11 Last updated: 2017-12-12Bibliographically approved

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