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Aspects of parastomal hernia
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Parastomal hernia (PSH) is a common complication to all ostomies, and all too well known to colorectal surgeons. Up to half of all stomates get a PSH. PSH may present itself as a protrusion or a bulge of the stoma that contains bowel or other content of the abdominal cavity. The symptom load varies from none to debilitating. An unknown fraction of patients with PSH receives correctional surgery. The overall aim of this thesis was to investigate prevalence and treatment of PSH in Sweden, explore whether prophylactic mesh when constructing a colostomy is a viable option for prevention, investigate the health economic impact of PSH and probe into the patient’s own experiences of living with a PSH. The thesis is based on both qualitative and quantitative research. Paper I and III are a randomised controlled multicentre trial, paper II is retrospective audit of the treatment of PSH in Sweden, paper IV is a health economic analysis of colostomy costs and paper V is an interview of survivors of colorectal cancer, with a colostomy and PSH.

The conclusions are as follows: The frequency of PSH surgery was much lower than expected, no specific risk factor could be identified, and perhaps centralisation of surgery should be considered. Most common cause for surgery was cosmetic. Prophylactic mesh in a sublay position don’t prevent PSH but doesn’t seem to add significant complications. PSH cost no more than a colostomy with no PSH, regarding appliances and stoma nurse visits. The common theme of long-time rectal cancer survivors with PSH is coping and a deep sense of gratitude being a survivor.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2023. , p. 72
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2262
Keywords [en]
parastomal hernia, colostomy, surgical technique, patient experience
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-216046ISBN: 978-91-8070-170-9 (print)ISBN: 978-91-8070-171-6 (electronic)OAI: oai:DiVA.org:umu-216046DiVA, id: diva2:1808515
Public defence
2023-12-01, Aulan, Sunderby sjukhus, Sjukhusvägen 12, Sunderby, 10:00 (English)
Opponent
Supervisors
Available from: 2023-11-10 Created: 2023-10-31 Last updated: 2023-11-01Bibliographically approved
List of papers
1. Use of prophylactic mesh when creating a colostomy does not prevent parastomal hernia: a randomized controlled trial—STOMAMESH
Open this publication in new window or tab >>Use of prophylactic mesh when creating a colostomy does not prevent parastomal hernia: a randomized controlled trial—STOMAMESH
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2019 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 269, no 3, p. 427-431Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to determine whether parastomal hernia (PSH) rate can be reduced by using synthetic mesh in the sublay position when constructing permanent end colostomy. The secondary aim was to investigate possible side-effects of the mesh.

Background: Prevention of PSH is important as it often causes discomfort and leakage from stoma dressing. Different methods of prevention have been tried, including several mesh techniques. The incidence of PSH is high; up to 78%.

Methods: Randomized controlled double-blinded multicenter trial. Patients undergoing open colorectal surgery, including creation of a permanent end colostomy, were randomized into 2 groups, with and without mesh. A lightweight polypropylene mesh was placed around the colostomy in the sublay position. Follow up after 1 month and 1 year. Computerized tomography and clinical examination were used to detect PSH at the 1-year follow up. Data were analyzed on an intention-to-treat basis.

Results: After 1 year, 211 of 232 patients underwent clinical examination and 198 radiologic assessments. Operation time was 36 minutes longer in the mesh arm. No difference in rate of PSH was revealed in the analyses of clinical (P = 0.866) and radiologic (P = 0.748) data. There was no significant difference in perioperative complications.

Conclusions: The use of reinforcing mesh does not alter the rate of PSH. No difference in complication rate was seen between the 2 arms. Based on these results, the prophylactic use of mesh to prevent PSH cannot be recommended.

Place, publisher, year, edition, pages
Wolters Kluwer, 2019
Keywords
mesh, parastomal hernia, prophylaxis
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-142585 (URN)10.1097/SLA.0000000000002542 (DOI)000467458600023 ()29064900 (PubMedID)2-s2.0-85050207106 (Scopus ID)
Available from: 2017-12-07 Created: 2017-12-07 Last updated: 2023-10-31Bibliographically approved
2. Parastomal hernia repair; seldom performed and seldom reported: Results from a nationwide survey
Open this publication in new window or tab >>Parastomal hernia repair; seldom performed and seldom reported: Results from a nationwide survey
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2020 (English)In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 109, no 2, p. 96-101Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Parastomal hernia is common, but there are few population-based studies showing the frequency and outcome of parastomal hernia repair in routine surgical practice. The aim of this study was to identify patients undergoing surgery for parastomal hernia in Sweden and to define risk factors for complication and recurrence.

METHODS: A broad search of the Swedish National Patient Register 1998-2007 for all possible parastomal hernia repairs using surgical procedure codes. Records of all patients identified were reviewed and those with a definite parastomal hernia procedure were included and analyzed.

RESULTS: A total of 71 patients were identified after review of the records. The most common reason for surgery was cosmetic and the most frequent method was relocation of the stoma. Parastomal hernia recurrence rate was 18% during follow-up of a minimum 2 years. Overall, a surgical complication occurred in 32%. Possible risk factors were analyzed including emergency surgery versus planned, gender, age, indication for surgery, and method of surgery; none of which was significant.

CONCLUSION: The frequency of parastomal hernia procedures was much lower than suggested by previous studies. The number of procedures per surgeon was even lower than expected. No specific risk factor could be identified. Parastomal hernia auditing in the form of a nationwide quality register should be mandatory. Centralization should be considered.

Place, publisher, year, edition, pages
Sage Publications, 2020
Keywords
Hernia, abdominal wall, colorectal surgery, ostomy, risk factors, treatment outcome
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-154781 (URN)10.1177/1457496918818984 (DOI)000536875200004 ()30563418 (PubMedID)2-s2.0-85059001799 (Scopus ID)
Funder
Norrbotten County Council
Available from: 2019-01-03 Created: 2019-01-03 Last updated: 2023-11-01Bibliographically approved
3. No reduction in parastomal hernia rate 3 years after stoma construction with prophylactic mesh: Three-year follow-up results from stomamesh-a multicenter double-blind randomized controlled trial
Open this publication in new window or tab >>No reduction in parastomal hernia rate 3 years after stoma construction with prophylactic mesh: Three-year follow-up results from stomamesh-a multicenter double-blind randomized controlled trial
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2023 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 277, no 1, p. 38-42Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The primary objective was to compare rates of parastomal hernia (PSH) 3 years after stoma construction with prophylactic mesh or no mesh. A secondary objective was to compare complications requiring reintervention within 3 years.

BACKGROUND: Recent studies have shown that a prophylactic mesh does not reduce the rate of PSH contrary to older studies. Long-term data on efficacy and safety is however scarce.

METHODS: A randomized controlled double-blind multicenter trial. Patients planned for permanent end colostomy were randomized to either prophylactic mesh in the retromuscular position around the stoma site or no mesh. They were evaluated for PSH clinically and with computed tomography (CT) 3 years after stoma construction. Medical records of all patients included were also reviewed at 3 years to detect any abdominal or abdominal wall surgery during that period.

RESULTS: A total of 232 patients were randomized. At 3 years, 154 patients were available for clinical evaluation and 137 underwent a CT scan. No significant difference in PSH rates was seen between the treatment allocation arms (clinical: P=0.829 and CT: P=0.761, respectively), nor was there a significant difference in the number of reinterventions, but 2 patients had their mesh removed at emergency surgery.

CONCLUSIONS: Prophylactic mesh does not reduce the rate of PSH and cannot be recommended for routine use.

Place, publisher, year, edition, pages
Wolters Kluwer, 2023
Keywords
parastomal hernia, mesh, prevention, prophylaxis
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-202661 (URN)10.1097/SLA.0000000000005537 (DOI)000905219700014 ()35837972 (PubMedID)2-s2.0-85145304565 (Scopus ID)
Funder
Swedish Research Council, 214-7196Region Västerbotten, VLL-545001Norrbotten County Council
Available from: 2023-01-12 Created: 2023-01-12 Last updated: 2024-02-08Bibliographically approved
4. Impact of parastomal hernia on colostomy costs at 1 year: secondary analysis of a randomized clinical trial (STOMAMESH)
Open this publication in new window or tab >>Impact of parastomal hernia on colostomy costs at 1 year: secondary analysis of a randomized clinical trial (STOMAMESH)
2024 (English)In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 113, no 1, p. 33-39Article in journal (Refereed) Published
Abstract [en]

Background and aims: Parastomal hernia (PSH) is a common complication after the creation of a colostomy, with a prevalence of approximately 50%. Despite the high frequency, little is known how PSH affects the cost of colostomy care. The hypothesis in this study was that PSH increases the cost of colostomy care compared with not having a PSH.

Methods: Two groups with (N = 61) and without (n = 147) PSH were compared regarding costs of stoma appliances and visits. The population from a large randomized trial comparing construction of colostomy with or without prophylactic mesh (STOMAMESH) was used and cross-matched with health economic data from the National Pharmaceutical Register, 1 year after initial surgery.

Results: Patients with and without a PSH were similar in basic demographic data. No difference in cost of stoma appliances (with PSH 2668.3 EUR versus no PSH 2724.5 EUR, p = 0.938) or number of visits to a stoma therapist (p = 0.987) was seen, regardless of the presence or not of a PSH.

Conclusions: PSH appears not to affect costs due to colostomy appliances or the need to visit a stoma therapist, in the first year. The lesson to be learnt is that PSHs are not a driver for costs. Other factors may be determinants of the cost of a colostomy, including manufacturers' price and persuasion, means of procurement, and presence of guidelines.

Place, publisher, year, edition, pages
Sage Publications, 2024
Keywords
Colostomy, health economy, parastomal hernia
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-213413 (URN)10.1177/14574969231188021 (DOI)001046532600001 ()37563916 (PubMedID)2-s2.0-85167775479 (Scopus ID)
Funder
Swedish Research Council, 214-7196Norrbotten County CouncilRegion Västerbotten, RV-927121
Available from: 2023-08-25 Created: 2023-08-25 Last updated: 2024-05-02Bibliographically approved
5. Battle of the Bulge: a qualitative analysis of living with a parastomal hernia
Open this publication in new window or tab >>Battle of the Bulge: a qualitative analysis of living with a parastomal hernia
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Parastomal hernia (PSH) is a common complication of a colostomy. Approximately one third of patients have a PSH 3 to 5 years after surgery. There is much qualitative research into living with a stoma, less so when it comes to living with a PSH.

Method: A qualitative study using semi-structured interviews. The participants were participants in a large randomised trial studying the effects of a prophylactic mesh when creating a colostomy. All participants were survivors of rectal cancer. Inductive content analysis was used for data processing. 17 heterogeneous informants (age, gender, geographical location) were interviewed based on a saturated selection.

Results: A major theme was identified in the interviews; “patients coping with parastomal hernia.” In line with this we identified four core coping strategies; meaningfulness; knowledge-based coping; social-based coping; and problem-based coping. For each category further subcategories were identified. We found that a deep sense of gratitude, for survival rectal cancer impacted the informant’s perception on their general wellbeing. Furthermore, we found the paramount importance of stoma nurses, or similar health care workers, enabling the patient to overcome different problems with a PSH.

Discussion: There is a need to better understand the patient’s perception of living with PSH and how to cope with this. The purpose is to ease the transition into living with a stoma, and perhaps a PSH. The coping strategies identified in this report may be incorporated into teaching and information material and also be used by nurses and doctors meeting patients.

Keywords
parastomalt bråck, kvalitativ
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-216045 (URN)
Available from: 2023-10-31 Created: 2023-10-31 Last updated: 2023-10-31

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