Prophylactic mesh placement for the PREvention of paraSTOmal hernias: The PRESTO systematic review and meta-analysis

Abstract

BackgroundParastomal hernia (PH) is the most common complication after ostomy formation. Prophylactic mesh placement may be effective in reducing the rate of PH at the stoma site. The aims of this systematic review were to summarize the evidence with regard to the safety and effectiveness in comparison with the standard procedure without mesh placement and to identify important risk constellations.MethodA systematic literature search was performed in PubMed, EMBASE and the Cochrane library with no language or date restrictions. Randomized (RCTs) and non-randomized controlled trials (nRCTs) were included. The main outcomes of interest were PH (primary outcome) rate and stoma-related complications (secondary outcomes) such as stenosis or fistula. Statistical analysis included meta-analyses of pooled data and subgroup analyses.ResultsEleven trials (eight RCTs; three nRCTs) with a total of 755 patients were included. PH rate varied from 0% to 59% in the intervention and from 20% to 94% in the control group. RCTs showed a significant reduction of PH rate in the mesh group (OR 0.24; 95% CI 0.10 to 0.58, p = 0.034), whereas included nRCTs did not. No significant differences were observed in postoperative complication rates. Subgroup analyses showed superiority of non-absorbable meshes and sublay mesh positioning in open surgery.ConclusionProphylactic mesh placement is safe and reduces PH rate. A recommendation for prophylactic non-absorbable meshes in a sublay position can be made for patients undergoing open colorectal operations with end-ostomies. Further research endeavors should focus on patient-oriented outcomes, not only PH rate, with respect to tailored treatment in specific patient populations.

Ostomy-Related Complications

“…30 Another recent meta-analysis by Pianka et al corroborated these findings and supported sublay over intraperitoneal mesh position and an open over laparoscopic operative approach. 48 One study has looked at the efficacy of prophylactic mesh use in the emergency setting and did not identify a significant preventative effect on parastomal hernia formation after 1 year. 49 There remains limited data on the long-term cost effectiveness of prophylactic mesh use.…”

Prevention and treatment of parastomal hernia: a position statement on behalf of the Association of Coloproctology of Great Britain and Ireland

“…Twelve systematic reviews and meta-analyses have now been published regarding the use of prophylactic mesh during primary stoma creation [28][29][30][31][32][33][34][35][36][37][38][39]. All reviews have demonstrated a statistically significant risk reduction of PSH with the use of prophylactic mesh.…”

Preloop trial: study protocol for a randomized controlled trial

“…So far, the fear of infectious complications has discouraged the use of synthetic mesh in contaminated surgical fields. Nevertheless, the infection rate of patients with synthetic prophylactic mesh applied in contaminated surgical fields is similar to that of controls without the mesh at the time a permanent stoma was created [ 13 – 16 ]. The use of synthetic meshes as prophylaxis has also been shown to be safe in other contaminated abdominal surgery sites [ 15 , 17 ].…”