No Reduction in Parastomal Hernia Rate 3 Years After Stoma Construction With Prophylactic Mesh

Abstract

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.

Stoma Complications

“…12 Other studies report similar figures, with rates ranging from 2 to 28% for ileostomies and 0 to 48% for colostomies. [29][30][31][32][33][34][35][36] In general, loop stomas-especially loop colostomies-have a higher rate of parastomal hernia formation than end stomas, almost certainly due to size of the fascial defect needed to bring both ends of the intestine through the abdominal wall. Although there is no widely accepted criteria for sizing the fascial defect, most colorectal surgeons recommend keeping the opening as small as possible while still allowing the easy passage of the tip of a finger alongside the intestine since larger openings are associated with higher rates of parastomal hernia.…”

“…36 Similar findings were recently reported from the GRECCAR 7 trial involving 200 patients at 18 hospitals in France (31 vs. 28% at 2 years after surgery, p ¼ 0.77) 58 and the STOMAMESH trial involving 240 patients at 8 hospitals in Sweden (39 vs. 37% at 3 years after surgery, p ¼ 0.83). 35,59 Interestingly, no major study found higher rates of perioperative complications associated with mesh implantation, including surgical site infections. Rates of prophylactic mesh placement during ostomy formation do not appear to have increased dramatically, at least in the United States, suggesting that the decision to place or not to place mesh remains individualized.…”