From the Journals

Reinforcing mesh at ostomy site prevents parastomal hernia

 

Key clinical point: For patients undergoing permanent colostomy, prophylactic augmentation of the abdominal wall using mesh at the ostomy site prevents the development of parastomal hernia.

Major finding: The primary end point – the incidence of parastomal hernia at 1 year – occurred in 3 patients (4.5%) in the intervention group and 16 (24.2%) in the control group.

Data source: A prospective, multicenter, randomized cohort study comparing prophylactic mesh against standard care in 133 adults undergoing elective end-colostomy during a 3-year period.

Disclosures: This study was supported by Canisius Wilhelmina Hospital’s surgery research fund, the Netherlands Organization for Health Research and Development, and Covidien/Medtronic. Dr. Brandsma and his associates reported having no relevant financial disclosures.


 

FROM THE ANNALS OF SURGERY

For patients undergoing elective permanent colostomy, prophylactic augmentation of the abdominal wall using mesh at the ostomy site prevents the development of parastomal hernia, according to a report published in the April issue of Annals of Surgery.

The incidence of parastomal hernia is expected to rise because of the increasing number of cancer patients surviving with a colostomy, and the rising number of obese patients who have increased tension on the abdominal wall because of their elevated intra-abdominal pressure and larger abdominal radius. Researchers in the Netherlands performed a prospective randomized study, the PREVENT trial, to assess whether augmenting the abdominal wall at the ostomy site, using a lightweight mesh, would be safe, feasible, and effective at preventing parastomal hernia. They reported their findings after 1 year of follow-up; the study will continue until longer-term results are available at 5 years.

Open hernia surgery castillodominici/Thinkstock

Open hernia surgery

A total of 133 adults (aged 18-85 years) scheduled for permanent end-colostomy were enrolled in the study at 11 teaching hospitals and three university medical centers across the Netherlands during a 3-year period. They were randomly assigned to receive prophylactic reinforcing mesh at the stoma site (67 patients in the intervention group) or conventional stoma formation (66 patients in the control group), said Henk-Thijs Brandsma, MD, of Canisius Wilhelmina Hospital, Nijmegen, the Netherlands, and his associates.

In the intervention group, a retromuscular space was created to accommodate the mesh by dissecting the muscle from the posterior fascia or peritoneum to the lateral border via a median laparotomy. An incision was made in the center of the mesh to allow passage of the colon, and the mesh was placed on the posterior rectus sheath and anchored laterally with two absorbable sutures. “On the medial side, the mesh was incorporated in the running suture closing the fascia, thus preventing contact between the mesh and the viscera,” the investigators said (Ann Surg. 2017;265:663-9).

The primary end point – the incidence of parastomal hernia at 1 year – occurred in 3 patients (4.5%) in the intervention group and 16 (24.2%) in the control group, a significant difference. There were no mesh-related complications such as infection, strictures, or adhesions. “The majority of the parastomal hernias that required surgical repair were in the control group, which supports the concept that if a hernia develops in a patient with mesh, it is smaller and less likely to cause complaints,” Dr. Brandsma and his associates said.

Significantly fewer patients in the mesh group (9%) than in the control group (21%) reported stoma-related complaints such as pain, leakage, and skin problems. Scores on measures of quality of life and pain severity were no different between the two study groups.

“Prophylactic augmentation of the abdominal wall with a retromuscular polypropylene mesh at the ostomy site is a safe and feasible procedure with no adverse events. It significantly reduces the incidence of parastomal hernia,” the investigators concluded.

This study was supported by Canisius Wilhelmina Hospital’s surgery research fund, the Netherlands Organization for Health Research and Development, and Covidien/Medtronic. Dr. Brandsma and his associates reported having no relevant financial disclosures.

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