RESUMO
BACKGROUND: The optimal management and timing of the abdominal wall reconstruction concomitantly performed with stoma closure are controversial. This study aims to compare short-term postoperative outcomes after concurrent stoma reversal (SR) with incisional hernia repair (IHR) and SR alone. METHODS: PubMed/MEDLINE, Scopus and Web of Science databases were consulted to identify comparative studies. Random and common-effect models were used for the pooled analysis of the proportions and means. RESULTS: Three studies met the inclusion criteria and a total of 504 patients who underwent simultaneous SR and IHR (N.=200) or SR alone (N.=304) were included in the meta-analysis. Postoperative morbidity increased after combined stoma and hernia surgery with a pooled OR for Surgical Site Occurrence (SSO) and severe postoperative complications (Clavien-Dindo ≥III) of 1.72 (95% CI 1.02-2.90) and 3.83 (95% CI 1.46-10.02), respectively. No significant difference was found between the two groups in terms of mortality (OR: 1.66; 95% CI 0.64-4.27), length of hospital stay (OR: 1.37; 95% CI 0.73-3.47). and readmission rate (OR: 1.17; 95% CI 0.67-2.06). CONCLUSIONS: There is limited evidence suggesting that synchronous repair of SR and IH appears to be associated with a higher risk of SSO and severe postoperative complications. Therefore, a stepwise approach may be considered the best strategy in this setting.
Assuntos
Herniorrafia , Hérnia Incisional , Complicações Pós-Operatórias , Estomas Cirúrgicos , Humanos , Hérnia Incisional/cirurgia , Complicações Pós-Operatórias/epidemiologia , Herniorrafia/métodos , Tempo de Internação/estatística & dados numéricos , Resultado do Tratamento , Readmissão do Paciente/estatística & dados numéricosRESUMO
Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.
RESUMO
Objective: To perform a systematic review and meta-analysis on the effectiveness of prophylactic mesh for the prevention of parastomal hernia in end colostomy, with the ultimate objective to summarize the evidence for an interdisciplinary, European rapid guideline. Methods: We updated a previous systematic review with de novo evidence search of PubMed from inception up to June 2022. Primary outcome was quality of life (QoL). Secondary outcomes were clinical diagnosis of parastomal hernia, surgery for parastomal hernia, and 30 day or in-hospital complications Clavien-Dindo ≥3. We utilised the revised Cochrane Tool for randomised trials (RoB 2 tool) for risk of bias assessment in the included studies. Minimally important differences were set a priori through voting of the panel members. We appraised the evidence using GRADE and we developed GRADE evidence tables. Results: We included 12 randomized trials. Meta-analysis suggested no difference in QoL between prophylactic mesh and no mesh for primary stoma construction (SMD = 0.03, 95% CI [-0.14 to 0.2], I2 = 0%, low certainty of evidence). With regard to parastomal hernia, the use of prophylactic synthetic mesh resulted in a significant risk reduction of the incidence of the event, according to data from all available randomized trials, irrespective of the follow-up period (OR = 0.33, 95% CI [0.18-0.62], I2 = 74%, moderate certainty of evidence). Sensitivity analyses according to follow-up period were in line with the primary analysis. Little to no difference in surgery for parastomal hernia was encountered after pooled analysis of 10 randomised trials (OR = 0.52, 95% CI [0.25-1.09], I2 = 14%). Finally, no significant difference was found in Clavien-Dindo grade 3 and 4 adverse events after surgery with or without the use of a prophylactic mesh (OR = 0.77, 95% CI [0.45-1.30], I2 = 0%, low certainty of evidence). Conclusion: Prophylactic synthetic mesh placement at the time of permanent end colostomy construction is likely associated with a reduced risk for parastomal hernia and may confer similar risk of peri-operative major morbidity compared to no mesh placement. There may be no difference in quality of life and surgical repair of parastomal hernia with the use of either approach.